Subglandular breast augmentation is um I'm gonna do more subfascial augmentation.
It's been relatively new for me for 25+ years. I did all dual plane augmentations,
good long lasting results, 3 years, 12 years post op,
but in the last few years I've been going more and more to um subfascial augmentation.
Why? I started thinking about it when.
Pre-pectoral breast reconstruction became more popular.
I was at a meeting and Mitch Brown said something about how the breast doesn't
naturally exist underneath the pectoralis muscle and that really stuck with me removing
and exchanging textured implants for my biocell patients and my breast implant illness patients.
I saw what putting an implant under the muscle does to the chest wall,
um, and changing the smooth implants also made me rethink this.
And I started using these more on my transgender patients when I started seeing when
I changed to smooth some lower pole stretch and when I changed to subfascial I saw much more
position stability and even with very little soft tissue coverage you'd still I could still
get good results going subfascial but I had concerns visibility,
palpability uh is there a higher capture contracture rate?
What about mammograms?
Is subfascial and subglandular, does that make a difference?
Is there actually a subfascial plane and what difference in techniques?
This is a paper that was just published this month in the aesthetic surgery journal
comparing subfascial to subglandular augmentation and found that subfascial does
have superiority and capsular contracture and position stability.
And I think the fascial structure of the breast is a very underappreciated concept and
very useful. This is from uh Doctor Manuel Chicon who's
taught me a lot about the structures and respecting the breast boundaries,
superior medial, but especially in the inframammary fold and laterally for position
stability, getting that implants in that position with the.
of the breast natural tissue really does make a difference in what you do.
So who's a good good candidate for pre-pectoral augmentation?
adequate soft tissue coverage. I'm seeing more and more of these active
patients thick pectoralis muscles that really don't like the animation,
good quality skin. Be very careful with massive weight loss
patients, any laxity of the skin.
Patients who want large implants are gonna require some additional.
For and then family history of breast cancer because it does this make a difference in
mammogram we don't know that you can use any type of implant.
I tend to use smooth gel implants the volume used not just the width but the height of the
implant. I tend to use now uh moderate profile implants.
I ultrasound all of my patients now and I find a lot of high profile implants have flipped.
We use 3 dimensional imaging maybe mainly so the patients see their anatomy before surgery.
It's up on a big screen. Oh, my breasts are exactly the same.
You can show them that they're not and they'll understand it better afterwards.
It also gives them a range of implant sizes and so they understand there's reasoning behind the
sizes that we pick.
So this is a patient I'm gonna run through her case, not an easy augmentation.
She's a figure. Competitors, she has thick muscles.
She has some breast, uh, volume asymmetry, uh, infrarem fold asymmetry,
chest wall asymmetry.
She has a 12 centimetre wide um base width. I'm gonna use a 295 cc implant.
Instruments that I showed I used this morning, the lighted lighted boy,
uh, long retractors. You don't need a lot of special equipment.
I actually position these patients with their arms down to their side in a frog position.
We put wrist restraints on, uh, pad their elbows, tie this to the bed.
Then the breast is sitting where it naturally sits.
It's not being raised up by having the arms out to the side.
This is how the patient is positioned on the table.
Uh, my markings, I said before, not anything. I don't understand why I align with the nipple
up, the nipple down, how it's going to change my dissection,
but, um, so I don't have to, uh, extensive of markings.
So this is that patient. She has enough soft tissue coverage.
She has over 2 centimetres of pitch. She has a thick muscle.
I think the important thing to remember, I put my incision.
I'm using a 12 centimetre implant, so I put my incision.
I'm not quite the 5545. I like 50/50 more, so I'm using 6 centimetres
from the nipple with the. In on stretch, the thing to be very careful
about when you make your incision, don't pull up too hard or down too much because you're
gonna change where that fascia is and where your infra memory fold is and you don't want to
disrupt that err on entering the fascia a little bit higher than lower so you'll preserve
the um the integrity of the inframmory fold for support.
So I've uh dissected down let me go back to that one.
So I'll dissect down to the oops.
Um Yeah, so I dissect down to the um fascia, and it's usually pretty
obvious, um, where that fascia is. I wasn't sure when I first changed from dual
plane to uh um.
Uh, doing above the muscle, is there actually a plane on the,
on the transgender patients, it's very clear. It's just as clear on these patients the
majority of the time, um, I think some of ours are dual plane,
sub fascial where some of it under and some below, but for the most part it is actually a
very clear, um, obvious plane when you get down to it.
I'll skip this and you can see here. It is there is a definite plane.
Make sure you always know where you are, tension and counter tension,
um, as you're doing the dissection.
uh, don't go too far superiorly. I think the fascia provides a really good roof
to keep the implant from going too high, especially in a con uh constricted breast
patient. Don't dissect too lateral under dissect these
pockets go to the anterior axillary line and no further than that.
Uh, I do use inflatable sizes. I sit the patient up.
I know that people don't think you should do that.
It takes 10 seconds. You fill it with air.
I'm just checking my pocket.
They don't have my implant in and have to make adjustments after the implants in place.
Uh, we irrigate the pockets with Betayne.
Uh, I use nipple shields. Everybody changes their gloves,
use a funnel. And I'll just put, just make sure the implants
laying in the right direction is not folded on itself, but the important thing I want to show
here is that I preserved this fascia in the lower pole,
and this is like a dam. It keeps that implant from falling down.
I'll tack that to the chest wall and to the superior of the scar it's fascia.
This is her at the completion.
The nurses hate these because they look under dissected.
They'll look very flat.
It'll the lower pole look flat. It'll look flat on the side.
It'll look too high.
I actually had to bring in pictures the other day to show the nurses that they look good a
year later. A post-op care.
I put him in a surgical bra for 3 to 5 days and then changed to a sports bra.
I asked him to stay in a bra as much as they can tolerate it for 6 months.
Uh, they can do anything they want with their arms the next day,
but no really heavy chest, uh, flies back, push ups for 6 weeks,
and here she is 6 months post-op.
This is a good candidate for this procedure. She has thick pectoralis muscles.
She has enough soft tissue cover.
This is, um, a 375 cc implant subfascial. It looks high and flat.
Um, there she is at a year lateral view high and flat at 2 weeks,
and it settles down with time.
I'm gonna show 10 consecutive results with 1 year follow up.
I'll also show you a fail and a complication.
I do this. This is from Lauren Rosenfeld from an editorial
he wrote, and he said if a Martian landed on uh came to one of our meetings,
they would think that the scientific method for plastic surgeons is to show before and after
results from surgery and showing these, I could, uh, all these results may impress you,
but it won't enlighten you at all.
So these are 10 consecutive results that I have 1 year follow up for.
So this is before, this is uh 2 weeks in a year, 2 weeks a year,
trickier one, implants high in the beginning. Here she is at a year,
same thing, 2 weeks 1 year.
Uh, this is a patient that should have had a mastopexy, but she didn't want the scars 2
weeks at a year. She looks OK, but she probably would have done
better with the mastopexy.
Uh, this patient, I actually used P4HB for her folds, very active patient,
very ill defined in memory fold, so I will, um, reinforce the fold and then lay the P4HB
over. Here she is at a year.
Another patient, 2 weeks, 1 year.
This is why I hate showing consecutive results. I chose the wrong implant on this patient.
Implants too big for her small chest. She looks pretty good at 3 weeks,
but here she is at a year lower pole stretch, inferior mal position on the left side.
She loves it. I don't.
Uh, this patient, uh, 3 weeks, 1 year post-op.
Another one Be careful, patient like this is a figure competitor in her 50s,
loose skin, thick muscle, uh, she did not want animation.
Uh she actually looks OK 6 months at a year, but when she's competing,
she has visible implant. You have to warn these patients when they get
their body fat down they're gonna have visible wrinkling and rippling.
This patient didn't have any attachments of the um skin,
the pre-sternal skin.
These are patients you should do uh dual plane to keep that separated.
She scared me. uh, implants are probably a little bit too wide
on her, but, um, ends up doing OK.
Here's an aesthetic fail. This patient should have had a mastopexy,
didn't want the scars, looks pretty good at 3 weeks at a year.
She just has larger, saggier breasts.
That was a bad choice on my part.
Another patient, she has a lot of stretch marks. She breastfed,
I think 7 children.
Uh, she is 6 months. She looks OK.
At a year, it looks a little too ptotic. The nipple position is too low.
She should have had a mastopexy.
The complication this patient, I'd done a breast reduction on her 20 years earlier when
she was 18. She's since had 4 children.
She, uh, wants implants. Here she is.
She came in. This was a 3 week visit.
Everything's fine. She looks good.
She did 6 hours later she felt a pop in her chest.
Of course it was a Friday night and uh, uh, her left breast became swollen.
Her husband's a radiologist, took her to the ER where he's on staff,
and they did a CT scan. You don't need a CT scan.
A hematoma is a clinical. Diagnosis, but and they admitted her.
Nobody called me until the next morning she called me and I said,
discharge. I'll see you um in the office on Monday.
Um, it's tempting to say, oh, that she wasn't in a lot of pain and the sub fascial patients,
they don't have the same pain that a dual plane patient would.
They, they can hide a lot of hematoma in that space.
This was a 150 cc hematoma. It would have caused her problems later on.
So I took her to the operating room, evacuated here she is a year later.
So the main thing is to be very careful in your dissection, stay above your fold to preserve it,
to use it to support your implant under dissect your pocket because it's going to stretch in
time. Uh, don't oversize your implants and use bra
support for 6 months.
Thank you.
And now, uh, doesn't need any introduction, Doctor Paullo Montemuro who we'll talk about
deep diving tolant choice shape, texture, and quizivity.
Thank you, thank you so much. Thank you for the invitation.
I'm gonna, um, tell you a little bit more about how I choose,
uh, implant. These are my, uh, disclosures and I mean the,
the question that we all ask ourselves is does the perfect implant exist?
And you know, just like there is no key that opens every lock,
I think it is so obvious to say that there is no implant to every breast and when we do a
consultation we see.
A lot of breasts and they are so different, you know, uh,
to each other, so it would be impossible to think that the same implant can be used on each
and every different breast.
And also, you know, like patients are different. Think for example,
if these two friends, uh, came to me and I did the operation on the tall one and the short one
came to me and said, Doctor, you operated my friend.
She looks amazing. Just please do the same implant on me.
That would be impossible, right? So patients,
they have different, uh, you know, body shape and soft cover distribution and all the rest.
And I try to actually convey this message through my social media,
for example, this is a picture that I have up on my Instagram showing 4 different girls with
basically the same, uh, result volume wise, but where 4 completely different volumes were used
to to obtain the same results. So this is kind of mind blowing for most of the
patients because they're like, OK, so how can I know which size should I get?
And I'm like surprised you to come to me or. To a plastic surgeon to do a consultation
because the that's the only way the ideal implant or an implant that if it's used it will
give you the same result doesn't exist. So how do I do it?
It's very simple. I use what I call a non-volumetric approach.
I'm gonna talk, um, like tell you a little bit more about that,
and I use what I call a wide armamentarium. So I have like a wide,
uh, toolbox, uh, to choose from.
So normal volumetric approach means that there are still some surgeons who just,
you know, ask the patient to take the top off, they look at the breast,
they take no measurements and they go like 300, 300, that's,
that's, that's all right. That's I think to me the wrong way to do it and
I use what I call the bio dimensional planning which means that the volume comes as the last
thing of the consultation. I measure the width I measure the height of the
implant. I select the projection on the implant and the
result of all this is the volume so I don't start with the volume.
The volume is like the last thing that I decide, even because if you wanna speak volume,
you know, let's say an implant that is 290.
An implant that is 290 could be an implant that is low projection with 13.5 centimetres in
width or it can be also 290, an implant that is 10.5 centimetres in width and
high projection.
So these two implants, they.
exactly the same volume, but I mean everybody can obviously understand that they would give a
completely different result. I mean this is the same size.
They're both 290, but they're completely different.
So the volume again of an implant is a function of with high projection and shape and you know
as an Italian I couldn't help but, you know, putting this picture of Dolce and Gabbana,
you know, like doing a breast segmentation is just going.
You know, to have a dress, uh, made to measure, you know,
we can choose, uh, between anatomic or around, you know,
like we have different width, higher projection, different textures or smooth implants,
different gels. So do I use smooth, do I use textures implant?
Well, I use a lot of texture implants and the reason why I use still use texture implants is
very simple. I use texture implant because anatomical
implants are textured.
And I couldn't run my business uh of breast aesthetics without anatomical implants and I'm
not saying I don't use round implants. I didn't say that.
I'm not saying texture or anatomical lims are better than round.
I didn't say that either. I'm just saying that in my toolbox I need
anatomical implants too.
So for me, um, texture implants are still indicated and you know this is.
Uh, uh, a publication that I did a couple of years ago with a lot of friends and colleagues.
You can see there's a lot of, uh, very well known names there and we were making the point
as to why we all think that anatomical limps are still needed on the market and again I'm
not saying that better or they should be used that and not smooth.
I'm just saying they're still needed on the market of breast aesthetics and this is another
paper of mine published last year on PRS, uh, in which I.
Um, asked, uh, a group of breast experts, uh, a lot of questions,
and one of the questions was, do you use anatomical implants and you can see there are
70 75%, so 3 out of 4 plastic surgeons still use, uh,
anatomical implants, so it's the majority of them.
And one of the reasons why we're often told that we shouldn't be using anatomical implants
is because they say there's no difference between round and anatomical.
So if there is no difference, why would we, why would we use anatomical implants if there is no
difference with round implants? So I'm like, OK,
but wait a second when you say that there's no difference with round,
do you mean that there's no difference in terms of final.
Appearance, I mean, the result is the same if you use a round or anatomical or do you mean
that there is the same indications for use regardless if it's anatomical or uh round?
I think it's two very different things. So when it comes to the appearance,
there are actually some studies up there I can think of the study by Ruby who gave uh um um a
set of pictures to to nurses and. Surgeons and ask them to guess uh whether the
the the patient received a round or an anatomical implant and like the I think 50% of
of of of those who were asked to answer only guessed right so the conclusion was you can't
tell if it's round or anatomical, but that's not the way you do it because if I show you
this picture and ask you, yeah, what do you think is is it a round or anatomical or if I
showed you this picture, I would ask the same question.
You would probably guess wrong, so you know you can't just show a picture and and try and guess
if it's an anatomical around implant. The only way you need you can have to
understand if there is a difference between round and anatomical is have the same patient.
This is the same patient with the same.
Uh, volume with the same width but just in one case round and another case,
uh, anatomical interest obviously in two different time frames.
So only in this case you can tell that there is a difference and I think everybody here can
guess which one is around and which ones and is anatomical.
I'm not saying which one is better. I don't care if anatomical is better around
anybody. Can like whatever they they they want to like.
I'm just saying that there is a difference between round anatomical implants,
and this was actually finally published by myself, I think a couple of months ago on PRS
which I made a study.
I had over my 16 years of practise 14 patients that changed implants from round to anatomic or
vice versa, having the same implant.
And I gave these pictures to a panel of surgeons who and you know all of them guessed
all 14 patients right so this proves that there is a difference in terms of uh appearance.
What about indications for you is there actually a difference between the indication of
around an anatomical implant.
Well, I, I do think that in some patients, if you, if you look at where the two diagrams meet,
uh, patients who are, who are easy, you know, those patients who come into our consultation,
we're just happy because we know we're gonna do a great breast augmentation.
They are easy. In those cases you can actually use uh around
or an atomic and it will not make any difference but in other cases if you look at
the diagram on the right hand side, for example, especially I would say when you have a
constricted lower breast or when you have a big asymmetry or like these cases.
I do believe that uh anatomical implant is the only choice if you don't wanna run into trouble
so any patient cannot just have an implant. There is an indication for use,
and this was published uh by myself with a few um colleagues uh uh a few years ago,
uh, on PRS if you're interested.
So you know, very quickly, uh, please take measurements.
That's the only advice that I can give you and the first thing that I do is I measure the,
the, the, the width of the breast just like a base plate in in order for me to explain to
patients is like I tell them if you buy shoes you need to,
to know how what what's your number? You have 38,
then you have to buy 38. You cannot buy 40 or 36 and that's the same
with the base width then you have to change to to to select the height of the implant.
And that's a little bit often disregarded by plastic surgeons,
you know, nobody, not, not many, uh, surgeons speak a lot about this,
you know, the implant of the, uh, the, the height of the implant should be chosen just
like this picture shows, just so half of the half of the volume of the implant is on top of
the implant and half is below the implant and you know,
it's very simple because when you have the chart and you think of the height of the
implant, you know, like you do like some measurements.
You know, the higher the implant and the further out the input is gonna go from the
existing in mammary fold because when you, when you choose a higher implant,
it's higher. On both directions because it has to be centred.
the chest wall is not only higher this way, it's higher so it also goes further down and
you know, the higher the risk, the further out you go and the higher the risk.
So stay close to the borders. That's my suggestion.
If you look at this press documentation, one of my very first cases I think 15 years ago,
you can see my planning there. I lowered theory fall by 3.5 centimetres.
What do you think happened here?
This happened of course you know I had a double bubble deformity because you know just as
simple as that you can see there, you know, like the inflamm fold,
the existing inframammary fold is still there.
This is not a mal position. This is a perfectly executed breast
augmentation, but the implant was wrong because it was too high.
Um, and third, you know, you don't forget the, um, uh,
the, the, the, the, the skin when you choose, um, projection of the implant because if you
have a tight envelope, if you have a constricted lower pole,
then you might need, uh, extra projection to allow for expansion of the constricted lower
pole. So in conclusion, like I said, the, uh,
ideal shape or volume or the ideal technique even for breast augmentation does simply does
not exist and I do believe that the most difficult part of breast augmentation is the
consultation because we all can do surgeries, you know,
once we've done a few, we all can get, you know, like very,
very good at doing surgeries, but consultations being able to say no sometimes to patients who
maybe want an implant that is too big for their anatomy.
So that's the most important thing because if we don't measure patients and if we don't have
a wider momentarium, then we will be able to offer a very limited set of options to our
patients. And my last slide I asked John if I could show
this. I became the president together with Nicola
Rocco of the NBN breast meeting that is held in Milan, uh,
every year, and this is this year is 12th to 14th of December,
so I hope to see many of you there. Thank you.
Thank you now a very interesting.
Uh speech how to downsize implant without mastopexy made by Abu Della Pina.
Thank you very much. Well, I'm Abel de la Pena from Mexico,
and I really very much appreciate the opportunity to be here at the London press
meeting, uh, with this outstanding faculty and basically because all of us
would like to know how to deal with our more demanding patients every day.
And I guess there is.
There is no other structure in the human body that had received so much attention that had
developed techniques and that has stimulate the creativity of plastic surgeons like the
breast. And don't you find amazing how uh social
trends are about evidence-based medicine?
We've been inserting breast implants the last 30 years with aesthetic and reconstructive
goals, restoring security and self-esteem to our patients who had gained femininity,
shape projection and breast volume distribution.
And the thing is that uh nowadays we have a new trend because patients are gaining
weight. They have breast dosis after uh placing some
implants they have upper breast fullness in this harmony with the nipple areola complex and
shape changes with vertical elongation.
And in order to downsize uh volume in patients with implants we need basically to
evaluate one thing and this is the ratio between the breast volume and the implant
because if we can do this then we will be able to understand if we were gonna be able to do
what Marlene asked me to talk about that is how to do uh downsizing without a mastopexy.
So in order to do this, the first thing is can we really reduce breast volume without
scars? We've been working in this topic for the last
10 years, and we certainly believe in the vischolastic properties of the tissues,
which means like in this case uh we have a breast uh volume which is very high
and we would like to make it shorter.
But the thing is that we don't wanna have scars for this kind of operation.
So is this possible?
Well, the thing is that after we do the procedure with the ultrasonic lipos culture and
radio frequency, everything at the same time, you can see the evolution of the patient during
the first year. And it seems to me that we have not only the
possibility of reducing the breast volume but also we're uh making a reposition of the
Nippolobiola complex.
And if we wanna do this the same way that uh a semester makes it without
scars, then we have to use technology in order to gain this kind of results
so.
Is it possible to reduce the breast volume without an SEtsy?
Let's see if we can do it, uh, but the first thing is I'm gonna be speaking of this on
Friday, so, uh, during the technology so we can explain more about how to do the breast
reduction with scarless, uh, possibility. But here we have a patient that had breast
implants and she wouldn't get removed because these new trends of having less volume on the
breast. And so are we able to do the explantation
without a scar? Well, the thing is that we have to first of all
we have to do to see if we have a symmetric in from my fold if we have a symmetric,
uh. Uh, uh, breast volume and we can see that we
have on the left side not the same volume as the right one.
So how are we gonna manage these things?
Well, the first thing to do is we have to reduce the volume of the breast and then we can
do the explantation and so when we do the the.
When when we start doing the the ultrasonic lipos sculpture in order to get uh the better
symmetry on both sides we will be able to start dealing with this so we're having
the same amount of implant and the same amount of breast tissue.
Then once we take the implant out we're gonna do a capsule of plastic but the most important
thing is we wanna lift the whole uh breast gland on top of the pectoralis muscle
because when we finish doing this we have uh the possibility of forming the new mount of the
breast. And we will be using the capsule as well,
so first of everything we wanna have a nice cleavage.
So that's one of the most important part when we're doing uh explantation and we're restoring
the breast, and we're gonna be using in all these cases a mesh in order to fix everything
to the mesh on top of the pectoralis muscles.
And you can see here with the defining the out the the external part of the breast in order to
make a very nice curve because we have lifted all the gland and all the uh tissues of the
axillary space and put it on top of the pectoralis muscle that is fixed with the
with the mesh and here with the transo you can see that the patient had a new volume a new
volume distribution and we had no implants in this area.
And so at the end of the surgery, of course we have to place fat all over in a radial way all
over the gland especially for the cleavage because this is the place that we want to
maintain the cleavage in the patients that have no more implants in this area.
And you can see that we can do this without and uh without the scars because we
approached this through the inframammary fold that it was the the scar had that she had done
in order to place the implants and.
When you can see we can reduce the volume we can maintain the same shape that the patient
had before the implant was removed and we don't have uh the necessary place more
scars on the breast.
Here's another young patient that had a very bad result after uh breast augmentation.
She was sent to me in order if I can convince her of redo the surgery and maintain the
implants on. So she refused to have that.
She had also this, uh, dynamic alterations of the of the of the breast because when
she moves the pectoralis muscle, then we have an asymmetric.
How are we gonna do this? Well, the first thing is we can do it through
the same incisions that where she had the uh breast augmentation through the periareolar
space, but we know that we have two different, um.
Measurements on the right side on the left side because we have a bottoming out on the left
side and we we have to fix this with the inframamma sulcus so we have to redo the
inframammary sulcus we are going to use the mesh in order to put all the tissues that we
have on top of the pectoralis muscle and in this way we didn't have to redo or do more
scars than the ones that she had and.
Basically, uh, what are the principles that we do in order to do this kind of operation first
and the most important part is we have to redo the amount of the breast and in order to do
that I really need a mesh in order to be fixing everything on top of the pectoralis muscles I
have to improve. If the the the breasttosis and if uh possible
to have a nibulolla complex repositioned before doing that.
So here we have another patient and we we know that she she's her implants has done through
the periareolar space so we're gonna do the the operation explantation.
And I'm gonna need fat in this lady. So if I'm gonna need fat for this,
I'm gonna use it from the abdomen and I'm gonna use the periareolar.
I'm gonna downsize the implant to a smaller one and obviously,
um, the best part that I like when I do this is, uh, the Benelli around is the is the best way
to close. The wound so we know that we can redistribute
the volume at the same time that we're closing and the implant is gonna help us not to push
the, the breast down.
So when we do this we can see that we have reduced the volume of the breast we have
redistribution of the volume and at the same time we have the opportunity to get uh.
Uh, some fat from the abdomen and improve also not only breast but also the
abdomen and with this in mind, so, uh, can we do this kind of operation in every
single patient, uh, most of these ones I'm gonna need the mesh and the mesh is the one
that is gonna help me to maintain the tissues in position.
So once we take the implant out.
We're gonna start dealing with the capsule, but the first and more important part is that we
have to free all the gland from the pectoralis muscle and.
Once we free it from the lateral part from the middle part and we can lift the whole uh breast
up in the tissues then we deal with the capsule if the capsule is OK and it's a very thin
capsule, we can just burn it out because I'm gonna put the mesh on top of it and now I'm
gonna have a very nice tissue in order to have a nice uh wound healing this area.
And as you can see, I always have a small, uh, flap from inferior pedicle flap
that is gonna help me to fix everything.
Uh, so we're gonna fix everything to the pectoralis muscle,
but we're gonna be aided by this mesh.
Now this mesh is a 50% absorbable, so you have like monocrylic polygeca front half of
it and the other half is polypropylene. I've been using this for the last 10 years and
fortunately it's, it's a mesh that goes very well.
And fortunately don't have any trouble with it and what you can see so we can maintain the
shape of the of the breast and without adding any kind of scars and probably one of
the question is can we do this in every single patient?
Well, no, the second and more important part of this is to know where is the position of the
nipple areola complex.
If we know exactly where the uh nipple areola complex is,
then we know that we are gonna have more of these operations.
So, uh, this one is a patient with optosis, so we're gonna use the inframamma fold in order to
improve this, do, and, uh, the explantation, and once we do it,
we know that we can maintain the shape.
And obviously she had previous surgery so we just reduced the size of the areola and we can
improve it again. I'm gonna be using a lot of fat from the
abdomen because this is gonna help me to maintain the shape of the of the breast and at
the same time improve it.
Can we do the same thing in this kind of patients?
The answer is no. I mean this kind of patients,
if we're gonna do an explantation, we need the mastopexy.
And so we're gonna grab fat from the uh from around and then as this is a
polyuretin cover implant we need a total capsulectomy so the capsule and the implant are
gonna come together. I'm gonna free it from all at the top of the
muscle and I'm gonna free the.
Gland from the implant and once we have this, this is one of the great things that I love
about polyureta and even though this patient has been with 10 years with the implants,
you're gonna see that the capsule is always pliable or at least more pliable than the ones
that I've seen with the uh with the smooth implants from the late 90s and the fir
the beginning of the 20 21st century.
So in this kind of implants you can see the implants maintain a very nice texture.
It's very easy to take the implant out of the capsule and it's very easy to do the the total
capsulectomy and again you can see exactly what I mean in this open surgery that I'm gonna
fix the inferior pedicle implant to them.
To the mesh and once you have fixed everything into the mesh,
then we're dealing with a brand new here you can see how the inferior pedicle is fixed to
the mesh so I'm pulling all the uh all the inferior pedicle up.
Into the mesh and I normally uh cut the dermis out of it because I don't want the
inframammary fold to be uneven so if you just section the the dermis out of it then you can
mobilise much more easily the inferior flap and obviously I'm using a lot of reading frequency
like you will see on on on Friday.
Because when you use uh rate of frequency uh in these cases you can see that we stimulate the
contraction of the skin and it helps a lot to get better uh understanding on this and
obviously fat transfer to the gland is one of the most important part,
especially for the cleavage that we want to improve it day by day.
And if we can do this, the possibility of achieving better results,
uh, it's a lot better. This is a very early result because,
uh, is one of the patients that we did one month ago.
And you can see that we can do the explantation and reposition the nipalala complex and do
not need another implant in order to get a better shape.
So I think that when we're dealing with these patients we will never know what our patient
thinks is the exact or ideal breast shape or breast volume.
But we do have to sit down with them and try to understand what are the expectations,
what are our choices in order to get better results because there's something that is very
important because misfortune can happen in any of the procedures that we do but
one of the things that is very important in Mexico is that misfortunes never came along.
So thank you very much for your attention.
Now, it's great pleasure to invite Doctor chair and Ms.
Rankers to talk about how to maintain possibility of avoiding capitalization and
legalisation of the infants.
Ladies and gentlemen, uh, dear colleagues, uh, their faculty,
Mr. Chairman, thank you for having me here.
The task I've been asked to talk about is pocket stabilisation by tissue preservation.
And a solution how to avoid and minimise implant map positioning.
And actually most other complications.
As one of the tools for providing the best foundation for the ideal breast.
So pocket stabilisation by tissue preservation and the concepts of the ideal breast.
That's my clinic in Stockholm, Victoria Clinic in in the archipelago.
You're more than welcome to come and visit us.
So, these are my disclosures.
Why? Why has to be the most important question
throughout life? Why are rest augmentations performed?
The purpose for a patient to have a rest augmentation most likely is the desire for
change of size and shape of a breast.
The purpose for a surgeon to perform a breast augmentation most likely is the desire to add
quality of life to the patient and the financial compensation therefore.
Now the question, how?
How do I, or could I or should I, as a doctor with best intention,
provide a patient the service or best augmentation, adding her quality of life with
least harm and best safety.
The key word always has to be safety.
By providing the concept of the ideal rest.
Based on the principles of the 5P, which is a foundation within our clinic,
patient selection education, proportional thinking, planning,
performance, and post-op care, all those factors create the environment for possibly the
idea of rest. So what is an ideal breast?
What do I mean? Is it shape, size, proportions?
Is it about implant properties, its surface, it's softness.
Is it a shell configuration and its elasticity.
Or is it by compatibility?
Avoiding short or long-term inflammatory reactions and diseases such as breast implant
associated ALCL and infections.
Or is it That an ideal breast is all about having these possible complications and
re-operations, such as capsic contractures, seromas, hematomas,
infections, rippling animation, mad positioning double capsule pain among others.
Without using drains or scisors.
Is it maybe all about a journey?
Least possible post-op recovery time and pain, is that the ideal rest?
With a short 2.5 centimetre scar in the Axilla or the IMF.
Mainly preserving the cooper's ligaments that stabilise the breast tissue.
Not cutting any nerves, vessels, or muscle.
Having the procedure performed under local anaesthesia.
In 15 to 20 minutes, going back home after 1 to 2 hours and enabling the patient to go
back to work or day activities the next day, is that ideal rest?
And even exercise within 3 weeks.
Or is it actually the mere fact that the patient does not have to eat any antibiotics
after surgery? As a matter of fact, not even having the
implant pocket flushed with betadinee or antibiotics.
Or maybe the answer has to or should be, everything mentioned should be part of the
ideal breast. Of providing that concept.
So how do we get there?
Is it possible? Well, John Tebbetts wrote in one of these
articles, he was one of my mentors, that we can divide complications in 3.
One related to the implants, the second one related to the surgeon or his surgery,
and patient related. And I think it's extremely important that we
find a way to divide where the complication occurs and why.
So. Why does someone that's been in practise for
close to 30 years, mainly using atomic catectural implants,
do a 180 degree shift?
I still use anatomical implants, but it is.
The outline of my bell curve.
So I incorporated the so-called Formicron implant into my practise that due to its
bicompatibly. By compatibility, don't instigate an
inflammatory response and no capsule formation.
And therefore cause a high risk of map position bottoming out the topic of this lecture.
Smooth implants are known to give uncontrolled tissue sturing and implants with less stability
over time. Those are facts.
So let's start with the implant, which has to be the foundation.
This is what I work with today, it's a so-called ergonomics too.
You can find them in ergonomic or diamond shape.
Now, this is our data, having worked with these implants.
The 5 P's and its principles have been developed on certain processes,
a process controlled by ethics, safety achieved by planning,
risk minimised by knowledge, aesthetics created by the systems of math,
and complications managed by experience.
But most importantly, by collecting data over time.
So this is a study we published a year ago.
It's over 6 years to centre 1,052 patients, and you can read these
articles. I don't need to present them, they're out there.
But one of the key Factors is that it showed a very low capital contraction rate,
which is very important.
It showed a low rupture rate, and we had a fairly high compliance,
which is really the key of a good article that you have compliance.
The important thing is that our data corresponded to other published data on these
devices. Now, as you can see, 1,053 patients.
Now the important thing is that the majority were primary.
And these were the complications.
And as you can see, the major complication that occurred was mal positioning.
The concept A problem that we knew, we just didn't know how to handle.
Why? Because we were using old techniques.
Implementing these with these 4 micron implants.
So my dad said, In the study on the primary, we didn't have one
cups of contracture, but it's not true.
That was presented in the study, but after that study, one case showed up.
So this is how the patient looked after 6 months, and this is our only capsule contractor
in the primary best dog with these 4 migraine devices.
Of course we're operated her and there's a 6 months down the road,
so there is nothing called no capsa contractures, they do occur,
but the likelihood are less with these biocompatible implants.
That's a fact. Now the most prevalent complication across all
cohorts was the mal positioning 2.9. However, after three years recognising this,
we changed our technique.
And the last three years we had a map position bottoming out of 0.5%.
So why? What did we change?
Well, one of the things is we change plane going from submuscular to subfascial
subglandular. And downsizing and the reason for that when
these implants were introduced initially they were so called microtextured saying they would
interact through friction, which isn't the truth they actually create no capsule formation
they're super smooth.
In that sense, so we downsized over time.
And by the way, we don't use any antibiotics because that was pretty obvious,
we didn't need that, and we recognised that so actually one,
the only one FDA investigator that doesn't use antibiotics.
No sizes, no sitting up, no drains now.
We also downsize placing smaller implants in the subglandinar plane,
realising that although they are smaller, due to the fact that they're on top of the muscle,
they would still give projection and volume.
Now, what we also realised, collecting the data is that patients that are predisposed due
to. Tissue lyticity, weak, stretch marks,
pseudototic breast, illidani syndrome, they are more prone.
To get into trouble using these devices.
So key is patient selection.
Now finding that perfect balance between shape, size and weight of the implant in correlation
to the existing soft tissue at time of implantation is a challenge.
So in our study initially not fully understanding the pros and cons of 4 micro nano
smooth, we had some patients with low post stretch and bottoming out,
like this one. And it's even more obvious, and this is 5 years
down the road. They were actually not holding up and the
implants were far too big, and she already had pseudotoic breasts prior to surgery,
but we didn't recognise that.
Today, however, learning from our mistakes, unless desire for bigger size,
concerns of stability and less connective tissue, Ian syndrome,
EO 2 is our preferred choice.
Now it's by compatible for my surface lessens the risk of chronic inflammatory actions.
We are aware of that. And this is the way it looks.
The surface is the topography is very homogene, and therefore it doesn't create an inflammatory
reaction and it doesn't create an affinity to biofilm contamination.
So what am I aware of today having used these now for more than 9 years,
and how to avoid implant map positioning?
Changing plane from implant placement, from submuscular to sharp subglandular subfascial,
and today, since 3 years, or actually 4 years, to hydra assisted aromatic blunt tissue
preserving augmentation.
This is through the IMF since 2.5 years and through the Ailla since 4 years.
Now, that I will share with you later this afternoon.
Stay tuned, thank you very much.
Thank you Charles. And now, um, Bramon composite breast
segmentation yet the balance right between fat and implant volumes.
Thanks. uh, thank you, thank you to the, uh,
organising and the scientific committee who, uh, uh, kind of,
uh, recognise this work and. Actually the sensitivity of uh Marlin who uh
decided to give a little hint homage to Eric Eulaire who was the one who uh
basically described first in 2013 the concept of composite um uh
breast augmentation.
Uh, in order to do this, I like to change gears. Uh, the following presentations,
all stellar have been, uh, focused on technical aspects.
I wanna give you a more scientific laboratory translational based one,
spice up a little bit the controversy and also, uh, you know,
have reasons why we do this or that.
And in order to do this, we're going to basically uh touch on the concept of a fat
graph standardisation and then see what is the contribution and distribution of these two
different variables.
Up to now we've been talking about implants. Now we're gonna be adding a fat graph.
So how are we gonna shape a composite breast augmentation made out of two elements permanent
one, a transient one.
Implant and uh fat grafting respectively and finally touch on the viscolastic effects of
mammoplasty and suggest an indication algorithm.
Well, all the fire graphs that we usually use today are made out of a lipo aspirate,
and if you take 1 20 cc syringe like this one, you will soon
realise that it is a coarse multi basic dispersion.
So we have an oil phase, we have a water phase, and then we have in the middle a tissue phase
and when these oil tissue and water phase go into increasing uh uh the breast,
you will all uh agree with me that when the water phase goes away,
then we have a problem, a problem of unreliability because the water component is
very variable between surgeons between um. Surgeries and in between patients themselves,
so standardise the contents of your graft would be the first step before we contemplate the
interaction between implant and graphs. OK, so please uh do uh familiarise yourself
with the at least the physical composition of your fat graph,
uh, just basically spinning an alley quote and then finding out what is the water,
oil, and tissue components of your uh your your fat graph at the end of it.
OK, how about the contribution and distribution of volume when we access uh or when
we contemplate uh composity, uh, composite.
Breast augmentation.
To that, we have to come up with the standardisation of volume.
You know, people, you know, measure volume in breast in a different way.
Uh, we chose to basically do this three dimensional uh algorithm,
uh, by which we superposed the post graph mesh over the pre-graph mesh and obtain a colour
contour map that gives a specific volume changes, especially when they have been
corroborated by MRI studies this being published before in 2015.
The first surprise to me was that when we placed a given volume of uh
implants, then and and subsequently after a curve of edoema,
then we, we were not able to match the volume of the implant with respect to the volume
obtained after placement of the implant.
So the second one was the fat.
The fat we all start up with saying, OK, if I put 10 ccs of fat in the breast,
the breast increases 10 cc.
that's wrong. And in fact, here's an experiment that proves
it, you know, in this um in this uh envelope we uh placed
increasing fat graph volumes and you can see here the post graph breast volume increment.
So the intraoperative volume that we gain, you know, on a CC per CC basis,
it ranges half of it.
And the whole thing goes like this, you know, and increases slightly when we reach greater
volumes. OK, that is how much of the quantifying
volume contribution of a composite approach to breast augmentation how
about. How much does it retain?
In fact, when you begin with smaller graphs with respect to the
capacity of the breast, you can see that we obtain reasonable intraoperative volume
rotation indices, but that goes down dramatically when we increase the fat
graph that we add on.
So bottom line.
The small graph volume feels breast better if you put a lot of fat graph in a
composite breast augmentation, you're not going to get that much volume increment with respect
to the fat graph you add.
Additionally, how about the how much of this volume that you obtain
intraoperatively, what happened postoperatively?
How much of that obtained in the operating room.
will be retained over a year.
So what happens is that no matter how much graph you put with respect to the
capacity of the breast will be retained, so there is no correlation between the
graph capacity ratio and the amount of graph you put because basically it will
resort to a point in which basically the envelope admits.
So the graph capacity ratio does not predict volume retention.
You can put as much fat graph as you want, but it won't be retained long,
long term. OK, how about the distribution of this volume
when we, uh, you know, plotted this and we began to see these changes over 18 months
follow up and these are the measures that the postoperative measures that we obtained,
you can easily see that initially we focused on implanting the fat graphs right on the upper
pole trying to get a fuller cleavage.
Uh, more defined cleavage.
However, relentlessly, the fat graft volume migrates
to the uh inferior pole. OK.
Why is that? What are the vischolastic changes that explain
these differences, both quantitatively and distribution wise?
So here what we did is we inserted a pressure transducer
right in the subcutaneous space in different patients in which we they underwent either
implant placement alone, fat graft alone, or composite.
So what what happens with this, oh by the way we did this until the skin
envelope would not accept any more fat grafting which we call that,
you know, um, uh, an overflow point by which you no matter how much
graph you put, it will just basically come out.
uh, now please realise that you know when we put the graph in.
And we increase the graft volume, the hydrostatic pressure underneath the skin
rises and basically reaches shortly of 30 millimetres of mercury.
However, when we do the same thing on composite.
Uh, breast augmentation, the, uh, hydrostatic pressure rises really high and it maintains
high. OK, but that's the hydro hydrostatic pressure.
How about the partial oxygen pressure that actually provides,
you know, diffusion, oxygen concentration to the oxidative metabolism of our
graphs. Look at.
This what happens is that in the fire graph there is uh this uh decrement on
the partial oxygen pressure but look at the sudden decrement when it is
under composite uh circumstances so how we put this all together.
When we put when we place a succutaneous fat graft only,
what happened is that we have a viscous elongation and elastic elongation of the skin
envelope, and yet as we increase the fat graph, the interstitial partial
oxygen pressure decreases, reaches an equilibrium at the reflow point,
and recovers in the postoperative phase thanks to the post-tress relaxation.
This transient hypoxia happens during uh the operation
or during the operation and shortly after the postoperative phase.
however, this hypoxia is maintained long in a long standing way
when we combine the composite mammoplastic fat and implants at the
same time, um.
59:59.360 --> 01:00:06.350 So what would be an indication algorithm that could incorporate this phenomena that we
01:00:06.350 --> 01:00:13.120 have just described in a way that is useful to our patients and to our good
01:00:13.120 --> 01:00:17.189 indicating uh uh uh uh uh capacity.
01:00:17.520 --> 01:00:20.830 So, um let me summarise for you.
01:00:21.239 --> 01:00:27.229 What we have in here is that these two components of the composite breast augmentation
01:00:27.510 --> 01:00:32.139 have a partial volume restoration intraoperatively.
01:00:32.429 --> 01:00:38.149 Now, postoperatively they have a transient retention, yet a permanent retention for the
01:00:38.149 --> 01:00:42.350 implant. The distribution of these volumes is migratory
01:00:42.350 --> 01:00:44.949 for the fact graph, yet fixed for the implant.
01:00:45.239 --> 01:00:50.429 The bottom line is that we have a differential volume contribution and a volume distribution
01:00:50.429 --> 01:00:52.590 in these two components of the composite.
01:00:53.620 --> 01:01:00.419 Breast augmentation and when we realise of that and we uh consider either an
01:01:00.419 --> 01:01:06.899 immediate composite a mammoplasty or a stage and by stage means either we stage the
01:01:06.899 --> 01:01:13.820 implant or we stage the graft, then perhaps the best indications would be outlined in
01:01:13.820 --> 01:01:18.790 here. You know, we have, uh, we have abilities for
01:01:18.790 --> 01:01:25.310 kind of a severe hypometia or asymmetries in which a hybrid augment mammoplasty would be
01:01:25.310 --> 01:01:27.189 best in an immediate fashion.
01:01:27.629 --> 01:01:34.580 However, perhaps in hypomensheus or under augmentation, an implant stage is more favoured
01:01:34.580 --> 01:01:40.550 or a graft stage is probably best used when we face double bubble deformities or riples.
01:01:41.179 --> 01:01:45.959 For me to finish this up and kind of uh provide some examples to you.
01:01:46.139 --> 01:01:52.800 Here's is an asymmetry on the patient's left breast and you can see here an
01:01:52.800 --> 01:01:57.300 immediate uh implant and a graft augmentation.
01:01:59.419 --> 01:02:05.979 This allows us to conform the small little details and differences and achieve
01:02:06.340 --> 01:02:11.050 as possibly as we can symmetry, you know, uh, in here,
01:02:11.100 --> 01:02:14.709 we have a case of, uh, you know, uh, um.
01:02:15.379 --> 01:02:19.080 Uh, under augmentation in a hypomastia, uh, case.
01:02:19.330 --> 01:02:23.719 This is the pre-op, this is the post-op after a graph, the patient,
01:02:23.969 --> 01:02:29.610 uh, you know, this wishes more, uh, uh, uh, an increment, and here we have a profile that
01:02:29.610 --> 01:02:35.370 definitely does not match the, um, the, um, uh, Patrick um.
01:02:36.360 --> 01:02:43.209 Uh, 45 to 55 uh ratio. And finally, and uh here we
01:02:43.209 --> 01:02:47.280 have an under augmentation and you can see here.
01:02:48.030 --> 01:02:52.969 The differences that the placement of the implant generates on the upper pole.
01:02:55.879 --> 01:03:02.459 Um, rippling is easily, uh, resolved with this fact grafting,
01:03:02.810 --> 01:03:06.540 and with that I just wanna say thank you so much.
01:03:06.770 --> 01:03:11.409 I would invite you to the Europe's in Palma de Mallorca, my hometown,
01:03:11.530 --> 01:03:18.169 my little island, uh, for Europe's, uh, is, uh, the largest plastic surgery meeting in
01:03:18.169 --> 01:03:20.959 Europe today for next May 25.
01:03:21.370 --> 01:03:22.959 Again, thank you so much.
01:03:24.830 --> 01:03:31.500 Now, but Now back to stage, Doctor Patrick Maloch talking about breast augmentation
01:03:31.500 --> 01:03:34.459 older woman addressing the skin and tissue laxative.
01:03:36.159 --> 01:03:39.540 Great, well, thank you once again er for the invitation.
01:03:39.989 --> 01:03:43.979 um. These are my disclosures and I'm talking today
01:03:43.979 --> 01:03:48.229 about surgery on the older breast, which is.
01:03:48.879 --> 01:03:53.409 It's quite an interesting subject because uh well we see plenty of them.
01:03:53.810 --> 01:03:58.379 Um and uh what is it with the older breast? Well, I think,
01:03:58.600 --> 01:04:04.389 you know, the main thing really is loss of volume, loss of uh tissue elasticity,
01:04:04.399 --> 01:04:07.780 and often totic breasts are the main things really.
01:04:08.229 --> 01:04:13.979 Um, but, um, you know, the same principles apply to the older breast as to any breast,
01:04:13.989 --> 01:04:17.060 and it's all about the usual tissue-based planning.
01:04:17.750 --> 01:04:19.310 Be careful with them.
01:04:20.110 --> 01:04:25.310 Uh, dimension and assessment of uh soft tissue, uh, thickness,
01:04:25.320 --> 01:04:26.389 elasticity, etc.
01:04:27.350 --> 01:04:32.939 and, uh, also a little bit of attention to implant selection.
01:04:33.070 --> 01:04:39.030 We have many implants available to us, um, all with different advantages and
01:04:39.030 --> 01:04:41.750 disadvantages, but there may be some.
01:04:42.320 --> 01:04:47.830 Um, elements of selection which are more inclined for the older breast,
01:04:47.989 --> 01:04:51.310 uh, than the, the younger breast, or maybe you get away with a bit less.
01:04:52.050 --> 01:04:54.790 I think there's also an argument to say in the older breast that,
01:04:54.959 --> 01:04:59.540 um, if you can avoid an implant, avoid an implant, um,
01:04:59.679 --> 01:05:06.479 you know, uh, I do a lot of mastopexy, um, we've um spoken about um
01:05:06.679 --> 01:05:08.679 the use of P4HB.
01:05:09.149 --> 01:05:12.340 Uh, Roy spoke about that earlier, something that I use routinely.
01:05:12.750 --> 01:05:17.139 um, and you can get a very effective mastopexy, particularly in the more mature woman.
01:05:17.429 --> 01:05:23.260 So I would always encourage them, uh, in the first instance to try and avoid implants if
01:05:23.260 --> 01:05:27.260 they want to, um, and even in those who've got really poor tissue qualities,
01:05:27.439 --> 01:05:33.219 you can get quite a reasonable outcome, even in the absence of an implant,
01:05:33.229 --> 01:05:37.260 as we see with all of these more mature women.
01:05:37.989 --> 01:05:39.639 So I think that's an important point.
01:05:40.330 --> 01:05:42.800 But if you are going to use an implant, as I said, you know,
01:05:43.030 --> 01:05:47.610 stick to your basics of implant selection, you know, about what you're trying to achieve,
01:05:48.010 --> 01:05:52.260 and um there's no reason that if you're selecting well,
01:05:52.310 --> 01:05:54.929 that you can't get a very reasonable outcome.
01:05:55.270 --> 01:06:01.590 This is a lady in her early 60s, uh, wanting uh a fuller breath,
01:06:01.669 --> 01:06:03.330 she'd lost a bit of weight over time.
01:06:03.629 --> 01:06:07.820 It's an anatomical implant, it has a polyurethane surface which is very,
01:06:08.290 --> 01:06:12.000 Uh, stable and it's in a dual plane.
01:06:12.570 --> 01:06:15.219 And I think with regards to implant selection.
01:06:16.260 --> 01:06:20.729 Um, I think a few things which are to be considered are the surface,
01:06:20.939 --> 01:06:26.929 the shape, and the gel, because a lot of these, um, uh,
01:06:27.179 --> 01:06:30.090 situations in the older bass, there is a lot of instability.
01:06:30.340 --> 01:06:34.939 So a preference for of mine is to use an anatomical implant,
01:06:35.300 --> 01:06:39.439 to use a polyurethane surface, which is extremely stable,
01:06:40.139 --> 01:06:44.199 um. And as we'll see, we can also play with the
01:06:44.449 --> 01:06:49.000 weight of the er implant because the less you load a breast,
01:06:49.409 --> 01:06:55.810 um the more advantage that is in in terms of um having poor tissue quality.
01:06:55.929 --> 01:07:00.370 So if you combine those, um you can produce uh quite an effect.
01:07:00.409 --> 01:07:05.270 This is Ed Sheeran's favourite implant, um, is the lightweight implant,
01:07:05.290 --> 01:07:06.969 you can see that you've got this um.
01:07:07.469 --> 01:07:11.129 Uh, microspheres and they're about 30% um lighter.
01:07:11.510 --> 01:07:15.320 They also have a property of the, of having this extremely cohesive gel,
01:07:15.389 --> 01:07:19.699 which again can be an advantage, can be a disadvantage, um,
01:07:19.750 --> 01:07:21.179 as we'll see.
01:07:22.280 --> 01:07:27.040 But the important properties are that they're lighter, they're very form stable,
01:07:27.090 --> 01:07:30.739 and when you combine them with polyurethane, um, uh, positionally,
01:07:30.899 --> 01:07:34.300 they're also extremely uh stable. So as I said,
01:07:34.340 --> 01:07:40.979 this is an implant that particularly in a lot of secondary cases would be um uh you know,
01:07:41.060 --> 01:07:42.729 one of my preferred choices.
01:07:43.219 --> 01:07:49.340 You can take advantage just to show you um of different implant properties,
01:07:49.379 --> 01:07:51.419 and we were talking about cohesivity.
01:07:51.939 --> 01:07:57.100 This is a lady in her late 50s, her previous implants in,
01:07:57.179 --> 01:08:00.330 they're already under her muscles, she has no fat, um,
01:08:00.340 --> 01:08:05.370 and simply by using a, um, a lighter weight implant which is more cohesive,
01:08:05.659 --> 01:08:11.659 you can pretty much iron out, um, those ripples. And there are other implants available which uh
01:08:11.659 --> 01:08:14.330 are also extremely cohesive, which you could use, um,
01:08:14.340 --> 01:08:18.555 in, in an equal manner, but. It's about knowing your uh your implants.
01:08:18.674 --> 01:08:24.645 Another typical example, uh, a woman, 61 year old woman wanting uh uh uh an augmentation and
01:08:24.645 --> 01:08:28.944 mastopexy, again, very thin skin, poor tissue quality.
01:08:29.234 --> 01:08:31.725 So I've used a lightweight polyurethane coated.
01:08:32.188 --> 01:08:37.458 Um, round implant in this lady, uh, and this is a two year post-op with a very stable,
01:08:37.869 --> 01:08:42.269 um, uh, postoperative outcome. You can see that lower pole pretty much hasn't
01:08:42.269 --> 01:08:45.789 moved. Of course, in the elderly or in the more mature
01:08:45.789 --> 01:08:51.789 women, expectations, um, are slightly different, perhaps they don't need a breast which is as
01:08:51.789 --> 01:08:58.659 per as upstanding as a younger woman, so it's also about managing expectation uh over time.
01:08:59.398 --> 01:09:04.148 Again, with, with, with more mature women, there'll be a lot of secondary surgery,
01:09:04.188 --> 01:09:08.508 lady who'd had previous uh implants, capture contractions, mal position.
01:09:08.838 --> 01:09:14.199 So again, swap these out for lightweight anatomical implants and completely re-dimension,
01:09:14.798 --> 01:09:18.639 and in this case, you don't need any extra support, any extra weight,
01:09:18.648 --> 01:09:22.559 etc. Again, similar case to swapping out a shape
01:09:22.559 --> 01:09:27.438 change from round to anatomical, a woman in her mid-sixties, um.
01:09:27.870 --> 01:09:33.430 Wanting to avoid scars from uh mastopexin again, you can use your anatomical implant to get that
01:09:33.430 --> 01:09:37.149 lift. Again, secondary surgery, lady had multiple
01:09:37.149 --> 01:09:41.979 procedures, round smooth implants, capture contracture, uh,
01:09:42.029 --> 01:09:47.459 and again by using your uh anatomical lightweight polyurethane coated implant,
01:09:47.470 --> 01:09:53.700 you can uh uh combine that with a a plane change and and create much more uh stability.
01:09:54.189 --> 01:09:56.200 Uh, this lady is um.
01:09:56.680 --> 01:10:00.479 A young lady, but shows many of the properties of uh that really thin,
01:10:00.540 --> 01:10:04.660 poor skin and the principle of using a lighter weight implant,
01:10:04.910 --> 01:10:08.779 combining that with a plane change in order to get a better outcome.
01:10:08.870 --> 01:10:13.430 And again, more secondary surgery, implants in for 20 years.
01:10:13.504 --> 01:10:16.584 Capture contracture, combination of waterfall.
01:10:16.854 --> 01:10:22.455 I've used a polyurethane coated anatomical implant, redone the mastopexy in order to
01:10:22.455 --> 01:10:26.555 completely re-dimension it and almost exactly the same situation here.
01:10:26.854 --> 01:10:30.205 Again, very poor thin skin quality.
01:10:31.660 --> 01:10:35.370 The implants had bilateral ruptured implants, capsules as well,
01:10:35.740 --> 01:10:38.209 um, and just er swapping out for the anatomicals.
01:10:38.500 --> 01:10:43.770 This lady we saw earlier, again, long standing breast implants swapped out for anatomical
01:10:43.770 --> 01:10:45.330 polyurethane coated.
01:10:45.779 --> 01:10:48.330 Um, and, uh, a much better outcome.
01:10:48.859 --> 01:10:54.220 Sometimes, and I rarely use uh mesh with implants because I use a lot of polyurethane,
01:10:54.259 --> 01:11:00.819 but this lady's skin was so thin, so unstable, that I did combine mesh with anatomical
01:11:00.819 --> 01:11:05.250 implants in order to provide some stability for her.
01:11:05.700 --> 01:11:10.310 So, you know, that's just some thoughts really in terms of both approach,
01:11:10.500 --> 01:11:13.790 um. Uh, in terms of assessing the soft tissues that
01:11:13.790 --> 01:11:19.520 I mentioned, but also think carefully about your implant selection in this challenging
01:11:19.520 --> 01:11:20.580 group. Thank you very much.
01:11:26.500 --> 01:11:30.580 Thank you so much. We are, we are not so much time but anyway,
01:11:31.109 --> 01:11:35.149 please, any questions from the floor for our speakers.
01:11:39.020 --> 01:11:45.490 Maurice Nice job, everybody. Those were really good,
01:11:45.689 --> 01:11:49.259 great presentations. Just got a question about how things change
01:11:49.259 --> 01:11:50.729 over time, you know.
01:11:51.560 --> 01:11:56.160 Patrick, you've shown great results, you know, with your 4555 principle,
01:11:56.240 --> 01:12:00.490 but what do you think the rate of changes over time?
01:12:00.830 --> 01:12:03.680 Uh, and I know there's a lot of factors that will influence the rate of change,
01:12:03.759 --> 01:12:07.319 but what have you observed, like, you know, 5 years out 10 years out,
01:12:07.439 --> 01:12:10.640 they don't always maintain those ideal proportions.
01:12:11.549 --> 01:12:14.899 No, but I, I think a lot of it comes from what you do at the beginning.
01:12:15.069 --> 01:12:18.279 If you're using conservative implants, if you're using,
01:12:18.430 --> 01:12:24.029 we, we have the auction of being able to use polyurethane, which is extremely stable,
01:12:24.149 --> 01:12:25.180 it doesn't move anywhere.
01:12:25.709 --> 01:12:30.299 Um, in fact, one of, one of the problems with polyurethane is that it doesn't move,
01:12:30.580 --> 01:12:34.160 so it's very easy to upwardly male position.
01:12:34.629 --> 01:12:37.950 So I think if you're sensible, um.
01:12:38.339 --> 01:12:42.549 And providing that there aren't great changes in the soft tissues,
01:12:42.620 --> 01:12:46.649 weight gain, weight loss, you get very stable results for for a very,
01:12:46.700 --> 01:12:47.700 very long time periods.
01:12:48.959 --> 01:12:52.040 Charles, you have the same experience too I patient selection is critical,
01:12:52.120 --> 01:12:54.790 but. You know, what about the patient who does lose
01:12:54.790 --> 01:12:56.319 20 or 30 pounds?
01:12:57.310 --> 01:12:59.720 Oh I definitely recognise.
01:13:00.819 --> 01:13:05.229 That is an issue and I think it's important during the consultation to inform the patient
01:13:05.229 --> 01:13:07.459 that you know this is not forever regardless.
01:13:08.069 --> 01:13:11.470 With all due respect, regardless of what implant would surface,
01:13:11.709 --> 01:13:15.629 there are pros and cons. You put a microtexture micro texture or
01:13:15.629 --> 01:13:19.660 polyurethane implant, the breast tissue above will descend.
01:13:20.109 --> 01:13:23.430 You put the smooth device in depending on the.
01:13:23.959 --> 01:13:28.689 Surgical technique and the size of the implant, that implant will descend with it and even
01:13:28.689 --> 01:13:31.040 maybe exaggerate the problem so.
01:13:31.850 --> 01:13:34.029 Time is an enemy.
01:13:34.310 --> 01:13:37.200 It's just a fact. We just need to address it in the right way to
01:13:37.200 --> 01:13:43.379 the patients. Other questions?
01:13:44.990 --> 01:13:49.459 I would like just to remark something that I think is is very important.
01:13:49.790 --> 01:13:51.270 We have seen charts and.
01:13:52.189 --> 01:13:58.870 Uh, but on completely opposite positions, talking about anatomical stable
01:13:58.870 --> 01:14:05.870 implant and smooth and um nano texture implant and in
01:14:05.870 --> 01:14:08.160 both cases, beautiful results.
01:14:09.049 --> 01:14:14.620 Then, uh, I, I think it's, well, you know, for the for the attendees,
01:14:14.640 --> 01:14:20.419 it's not so easy to, to understand why, what, how, um,
01:14:20.729 --> 01:14:22.520 if I have to go back or not.
01:14:23.259 --> 01:14:28.339 Um, I think that, um, Patricia, you moved from, from, uh,
01:14:28.350 --> 01:14:31.540 dual plane to sublandra very, very often.
01:14:32.470 --> 01:14:36.120 I think that is a very good position. Sometimes they do,
01:14:36.390 --> 01:14:39.620 there is an abuse all over the world about dual plane.
01:14:40.189 --> 01:14:46.600 Duual plane can cause uh waterfall deformities very easily if you have a medium volume breast
01:14:46.600 --> 01:14:53.600 and you put implant some muscular, you will have in a in a short time because 5 years is
01:14:53.600 --> 01:14:57.490 right they. If medium term, but it's quite,
01:14:57.560 --> 01:15:01.859 quite, quite good, but if you have after one year, you have a with for the family is,
01:15:02.600 --> 01:15:04.029 I think it's a great problem.
01:15:04.830 --> 01:15:07.879 Then it's the take home messages from this session.
01:15:08.750 --> 01:15:11.740 What is it? Well, I think, I think it's a very good point,
01:15:11.839 --> 01:15:18.140 and I think one of the things that we talk about, or we don't talk about enough is
01:15:18.370 --> 01:15:21.069 the artistry of plastic surgery.
01:15:21.479 --> 01:15:23.470 The word science is used a lot.
01:15:24.290 --> 01:15:31.149 In my mind, oftener in an exaggerated um form, because the fact is that we all
01:15:31.149 --> 01:15:33.509 have different hands, we have slightly different eyes,
01:15:33.549 --> 01:15:34.790 we have different ways.
01:15:35.149 --> 01:15:39.020 The beauty of our specialty is that we all do it slightly differently.
01:15:39.189 --> 01:15:40.859 We have different tools available.
01:15:41.430 --> 01:15:45.169 I know what I can achieve, achieve with the tools that I use.
01:15:45.669 --> 01:15:48.459 Charles knows what he can achieve with the tools he used.
01:15:50.009 --> 01:15:52.549 I'm not better than Charles, Charles isn't better than me,
01:15:52.750 --> 01:15:55.100 no one's better than anybody, it's the way we do it.
01:15:55.509 --> 01:16:00.660 And I think, you know, you reach a stage where, You get,
01:16:00.689 --> 01:16:04.379 you get a certain amount of predictability of what you can achieve with your hands and the
01:16:04.379 --> 01:16:05.729 tools that you have available.
01:16:06.259 --> 01:16:09.160 I think if you put that all together, you do it in a,
01:16:09.169 --> 01:16:12.459 a way that is, you know, safe and uh.
01:16:13.319 --> 01:16:18.540 Um, and you understand the, the, the pros and cons of what you're using,
01:16:18.669 --> 01:16:20.459 I think that's the beauty of our specialty.
01:16:20.709 --> 01:16:22.549 There isn't one right way and one wrong way.
01:16:23.299 --> 01:16:27.169 And I couldn't agree with you more, Pat, and, and here's the thing,
01:16:27.379 --> 01:16:33.620 this is an opportunity for each and everyone to see, to discuss with us and then feel what
01:16:33.620 --> 01:16:37.729 appeals to to to to you as a doctor within your practise, however,
01:16:37.790 --> 01:16:43.390 with that said. Sometimes we get lost in our striving of
01:16:43.390 --> 01:16:44.620 creating perfection.
01:16:45.390 --> 01:16:49.549 I mean, beautifully described by Pat, uh 45, 55, etc.
01:16:50.629 --> 01:16:54.529 Where I got a little bit lost, and I have to admit that was
01:16:57.520 --> 01:17:03.950 Sometimes when we get up on the podium, we say things, so many times we actually believe it is
01:17:03.950 --> 01:17:06.430 the total truth without really knowing.
01:17:07.689 --> 01:17:10.069 It is part of the way we behave.
01:17:11.200 --> 01:17:17.049 And and where I've changed my opinion and and the reason why I did it was of course due to
01:17:17.049 --> 01:17:20.169 ALCL and my role that I had with Allegan.
01:17:20.529 --> 01:17:25.890 I changed and I had to look at different alternatives because of ALCL and the problems
01:17:25.890 --> 01:17:30.200 that I'd seen over many years, but what I'd lost over the years.
01:17:31.390 --> 01:17:33.540 Is understanding the woman.
01:17:34.669 --> 01:17:37.600 As a man. I looked at the beauty.
01:17:37.640 --> 01:17:43.680 I looked at the perfect proportions, but today I'm able to perform a breast augmentation under
01:17:43.680 --> 01:17:47.839 local anaesthesia, talking to the patient with a very small incision,
01:17:48.240 --> 01:17:53.319 sub glandular, avoiding a lot of the issues that were related to the dual plane through a
01:17:53.319 --> 01:17:59.410 small scar, 2.5 centimetres, the patient going back to work the next day or to her family,
01:17:59.720 --> 01:18:01.029 and exercise.
01:18:01.529 --> 01:18:04.029 So for me it's it's just.
01:18:04.490 --> 01:18:08.529 A more fresh modern approach, and I'm not saying I'm right or wrong.
01:18:08.879 --> 01:18:15.589 Time will tell, but so far I I've been doing this uh concept now for 4 years,
01:18:15.799 --> 01:18:19.759 through the axilla and 2.5 years through the IMF, and,
01:18:19.799 --> 01:18:21.439 and you've seen the live surgeries.
01:18:21.839 --> 01:18:25.779 I had the pleasure of having Roy with me last week during the MEA procedure,
01:18:25.799 --> 01:18:28.069 which is part of this preservation concept.
01:18:29.109 --> 01:18:33.290 What it's gonna be your total practise or not I don't know.
01:18:33.819 --> 01:18:40.819 In my world, in my practise it is today the majority because women want this my my
01:18:40.819 --> 01:18:45.129 patient, they want this, they want the softness, they want to have that ability.
01:18:45.399 --> 01:18:47.930 Does it fit every patient? Absolutely not.
01:18:48.540 --> 01:18:52.220 But what I'm saying and what I think all agree with, be open minded.
01:18:53.509 --> 01:18:59.069 That that's the only thing and and try to think outside this this way we sometimes do.
01:19:00.009 --> 01:19:03.000 And and that's the only thing I'm asking for, be open minded.
01:19:04.279 --> 01:19:08.270 Then actually it means that whatever you you want to choose.
01:19:09.229 --> 01:19:16.200 You, you think about it, uh, try to understand what is the logical thoughts that
01:19:16.200 --> 01:19:19.959 you have behind the uh the idea of each surgeon.
01:19:20.439 --> 01:19:25.290 Uh, that probably they, they explain the, the experience, uh,
01:19:25.359 --> 01:19:29.490 that they got, they, they, we passed, we all passed through a lot of experience,
01:19:29.580 --> 01:19:33.959 different implants, different surgery. Can you imagine the uh the reconstruction we
01:19:33.959 --> 01:19:39.279 will talk in the next days about the pre-pack positioning until 10 years ago was something
01:19:39.279 --> 01:19:44.240 that was, can I add 11 more thing as well on the subject,
01:19:44.319 --> 01:19:47.600 I think the other thing which um especially for the younger surgeons is that.
01:19:48.250 --> 01:19:54.839 We all have different patient populations, and we all generate and create our own patient
01:19:54.839 --> 01:19:59.250 populations. And you know what my patients require,
01:19:59.609 --> 01:20:06.609 expect are different to what Paulo's, what Roy's, what Pat's and and you you
01:20:06.609 --> 01:20:12.160 almost generate a a patient that migrates to your style of doing things,
01:20:12.490 --> 01:20:13.640 likes what you do.
01:20:14.120 --> 01:20:19.529 Um, and different tools will be required for those different populations,
01:20:19.540 --> 01:20:24.180 and again, that's the beauty of what we do is that, is that there is no right or wrong way.
01:20:24.220 --> 01:20:28.459 We can only share our own personal and individual approaches and.
01:20:29.140 --> 01:20:31.569 Share with you what we can achieve with the way we do things,
01:20:31.700 --> 01:20:33.379 but it may be different for all of you.
01:20:33.700 --> 01:20:39.299 The other point that I think follow your patients, see what happens to them with time
01:20:39.299 --> 01:20:43.129 you know somebody can show a picture of somebody looks great a year post-op.
01:20:43.339 --> 01:20:47.899 I see my patients every other year for the first few years when the implants get older,
01:20:47.939 --> 01:20:51.810 I see them yearly we offer free visit. Visits we do ultrasounds we don't charge the
01:20:51.810 --> 01:20:55.720 patients for when you see what happens to your patients over time,
01:20:56.009 --> 01:21:00.279 you will change what you do because I tell the patients, I don't want you to just look good
01:21:00.649 --> 01:21:02.729 now. I want you to still be happy and still have a
01:21:02.729 --> 01:21:08.370 good looking breast in 10 years and avoid these patients that these implant cripples that will
01:21:08.370 --> 01:21:10.770 come because you oversize the implant you over dissect.
01:21:10.890 --> 01:21:15.720 The pocket, but if you follow your own patients, you'll learn and take your own pictures and
01:21:15.720 --> 01:21:18.870 look at your own pictures and see what happens in time.
01:21:19.080 --> 01:21:21.680 Charles taught me that. Yeah, I couldn't agree with you more.
01:21:21.759 --> 01:21:26.109 I mean, we follow our patients part of the practise with guarantees for 10 years.
01:21:26.359 --> 01:21:31.319 If there's any problem, we'll re-operate and only by knowing your own numbers because here's
01:21:31.319 --> 01:21:35.109 the thing. Regardless of who of these surgeons you would
01:21:35.109 --> 01:21:39.140 visit. If you believe that you can pick bits and
01:21:39.140 --> 01:21:43.629 pieces and create your own dish, it won't be the same as ours.
01:21:43.700 --> 01:21:49.529 So when we show, you need to understand that if you're diluting some small things within that
01:21:49.529 --> 01:21:51.700 surgery, the result will not be the same.
01:21:52.310 --> 01:21:55.470 So with that said, you need to follow your own patients with your own technique.
01:21:55.589 --> 01:21:58.140 Only then will you know your truth in your environment.
01:21:58.790 --> 01:22:03.370 If you don't measure, you don't know what to manage, and that is the foundation.
01:22:03.379 --> 01:22:08.209 We are extremely weak as a discipline when it comes to evidence-based medicine.
01:22:08.220 --> 01:22:09.359 It's just a fact.
01:22:10.049 --> 01:22:12.680 But with this said, with this type of meeting, we can do it better,
01:22:12.770 --> 01:22:14.720 so follow your patients over time.
01:22:15.569 --> 01:22:19.419 Thank you so much. I just said just one thing that I wanna pass
01:22:19.419 --> 01:22:21.209 through this. I got notes for every one of you.
01:22:21.569 --> 01:22:26.149 But Doctor Paolo, you just mentioned something quite important and I think that we're moving
01:22:26.149 --> 01:22:31.339 much more by our pain and our data that we collect and by science as well,
01:22:31.680 --> 01:22:36.549 but you mentioned a lot about measurements and I, I really like your papers about that and it
01:22:36.549 --> 01:22:40.549 completely changed. I, I, I would ask the audience how many of you
01:22:40.549 --> 01:22:43.660 take measures of the height of the implant, the width of the breast,
01:22:43.830 --> 01:22:48.910 uh, the stretch, and, uh, prior to surgery, how many of you?
01:22:51.279 --> 01:22:54.040 How many are based on the experience just look at, OK,
01:22:54.200 --> 01:22:55.410 what 31006.
01:22:56.709 --> 01:22:58.720 What what is it that most of the people, and that, that,
01:22:58.759 --> 01:23:02.729 that I, I really think is one of the most important things to respect the anatomy,
01:23:03.000 --> 01:23:06.759 and I would leave this as a take home message for especially for young surgeons.
01:23:07.359 --> 01:23:08.379 Thank you very much.