So good afternoon everybody. We started this afternoon session,
which is a very nice session, giving the possibility of a very nice price,
so I. Everyone has to try for the next year to
present a paper in this session, 1000 pounds for a travel grant,
so I think it's fantastic.
We will present with Ara and every paper has 5 minutes and just one
question after.
The first coming on the podium is Elizabetta.
You cannot manage what you do, not measure.
Good afternoon to everybody. I'm Elisabetta.
I'm a consultant plastic surgeon in Italy in Bologna, and I will present my research study
on breast measurement changes performed between Italy and Canada with the support of bump
plastic surgery with Doctor Elizabeth Findley.
This is the first part of the study, uh already published in the static surgery journal.
We are currently working on the second part of the research.
As known, the principal goal of aesthetic breast surgery is to recreate a pleasing breast
shape trying to meet patients' desires.
In the literature, we talk about proportion, shape, position,
but uh we miss a very systematic guideline useful for the pre-operative breast assessment.
A simple method of breast analysis is to firstly evaluate the breast footprint.
Secondly, go to the mound of the breast, and lastly to the nipple position.
The breast footprint consists of 4 landmarks. We have the upper breast border,
the lower breast border, the lateral breast border, and the middle breast border.
To find the upper west border, it is better to fold the breast up rather than push it up.
We have different patients, so we can have long or short footprints.
In a breast augmentation, we know uh the goal is to centralise the implant behind the
existing nipple position.
In a breast reduction, we have to choose the right pedicle with the right skin and
parenchymalization patterns.
For the mastopexy, we should rearrange the tissue, trying to not use the skin as a brazil.
For a mastopexy augmentation, I think an interesting concept is the minus plus technique
of Doctor Paul Regno.
So the aims of this research was to provide the framework to better manage our result.
We analysed consecutive patients, underwent 4 different aesthetic breast surgery procedures
in 7 years of follow up.
We had 539 patients for breast augmentation, 388 for breast reduction,
244 for mastopexy augmentation, and 90 patients for mastopexy.
We analysed 5 anthropometric parameters from the clavicle to the upper breast border,
from the suprasternal note to the inframammary fold, from the suprasternal notch to the nipple,
from the upper breast border to the nipple, and from the chestsme line to the nipple with the
preoperative and post-operative follow-ups.
Statistical analysis were performed.
In the breast augmentation group, we have subgroups of patients with smaller and larger
implants and subglandural and submuscular implants.
We use superior pedicle or supraoredal pedicle for the mastopex augmentation group.
The vertical scar approach plus liposuction for the breast reduction.
And the superior or sor medial particle with rivero or graph flap for mastopexy.
If we look into the results for the breast augmentation, we can notice a shortening of the
clavicle to upper breast border parameter and the lengthening of the other ones also
confirmed in the long-term follow-up.
If we see a different subgroups of patients for breast augmentation,
we can see that some muscular implants tend to go higher,
but at the same time lower.
With the erasing of the nipple due to the pendulumma factor of the lowering of the
inflammatory fold.
For the mastopex augmentation, we had similar results as in the augmentation with the major
raising of the upper breast border.
Confirmed in the long term follow up.
We didn't find any significant difference in breast reduction,
also confirmed in the 4th year of follow up, and a correlation between the amount
of removed tissue and the parameter changes.
For a mastopexy, we had a slight raising of the upper breast border of around 1 centimetre,
not confirmed in the long term follow up.
So to sum up, uh, with the breast augmentation, we can raise of around 2 centimetres the upper
breast border, but low footprints will remain low.
So larger implants are not always the solution.
In a master pack segmentation, we can raise slightly more the upper west border.
We cannot change the upper west border in a breast reduction.
So I think that the upper breast border could be considered a most reliable landmark to
detect the UNIO position, because sometimes the IMF could be a misleading landmark.
Here we can see that the upper west border cannot change,
cannot change. And in a mastopexy, we can gain a projection
but not an improvement of of the upper pool fullness.
So I think in the literature we miss a lot of studies to put measurements together also with
the addition of the vertical distances.
How to achieve consistent results as surgeons we should know what the measurements show to be
able to better manage patient expectation, trying to explain not only the benefits but
also the limits of our surgery and keep it simple.
I think that this research could be shifted also in the breast reconstruction file also in
the case of contralateral symmetrization, uh, with the addition of vertical distances and the
support of uh technological advancements in digital 3D imaging systems.
Thanks for your attention.
Just one question, someone a question for her.
And we move forward. Thank you very much.
We apologise if we do cut you off. We're on a very,
very strict time schedule, so we'll also skip questions if needed.
The next presentation is from Charles Cayes, my 1st 900 pre-pectoral DTI reconstructions.
Mhm. Good afternoon.
Thank you. Uh, I completed my plastic surgery residency in
1996.
I hate to date myself with Doctor Scott Speer at Georgetown,
and consistent with those teachings at that time, for 20 years,
my breast reconstruction protocol was two-stage breast reconstruction expander implant under
the muscle. And that was the way it went for 20 years.
In October of 2016, however, I was in a meeting with Scott and he said two things which was my
game changer. The first thing he said was that everything he
taught me, he did differently, which is a little disconcerting.
But I, in his uh amiable way, he was telling me that don't be afraid to innovate,
to think out of the box.
Second thing he said was that if a woman was going to need radiation post mastectomy,
he went direct to the implant.
So literally, This patient shows up my office the very next week in October of 2016.
She had finished neoadjuvant chemotherapy. She was scheduled for bilateral mastectomies.
The radiation oncologist wanted to hit her with radiation a month after surgery,
and the patient told me she wanted to be as big as possible.
It had to do something with the Harley Davidsons that she rides a motorcycle.
I don't understand, but so I went to my surgeon and I said,
Can you give me the viable flaps because I wanna put this implant on top of the muscle.
And uh he was intrigued by the, by the technique.
So these are the flaps he left me.
Um, I had been using the spy for vascular imaging since 2011 for five years,
and I thought, well, you know, I'm gonna check his work,
and certainly the flaps look viable and with robust vascular flow.
So, The next step was how do I cover my implant.
Now I know a lot of us advocate for wrapping the implant.
To me that was counterintuitive.
We placed an implant under the muscle for two reasons to provide upper pole,
slope, and tissue coverage.
My ADM would be my tissue coverage, but what I did is I went down from the clavicle about 2
centimetres. I elevated a partial thickness sleeve of
pectoralis muscle, and that was the edge to which I would sew my ADM.
That is a 16 by 20 sheet of ADM we used.
Actually back then I only had 8 by 16, so I had to sew two sheets together to make a 16 by
16. So there's the implant in place under the ADM.
This shows a picture of a patient I revised, kind of shows the muscle elevated slightly in
the ABM adherent to that.
This is the patient about 2 weeks after surgery. You can see we have a nice upper pole slope,
no rippling, she's healing well.
This is her about halfway through radiation to the right breast.
As you can see she's still doing very well.
This is actually her 3 years postoperatively.
No revisions required, no fat grafting, a relatively nice outcome.
And this I took last October 6 years post-op radiation to the right side,
no fat grafting, no revision, direct implant pre-pectoral with the ADM covering,
anterior covering.
This patient also showed up later that same week.
Obviously, I have more than enough skin.
She uh received the pre-pectoral reconstruction and as you can see,
she had radiation as well to the right side, a little hyperpigmentation along her clavicle.
excuse me, she also did very well.
Here's another patient, came to the office again more skin than really needed,
showing middle picture shows the radiation delivered and the picture to the far left shows
her year post radiation.
No fat grafting, no revisions.
Another patient a year post-op, a PEy on the right, pre-peer reconstruction on the left,
and she also had radiation on the left side.
This patient had a right lumpectomy and radiation, now had a recurrence in the right
breast. Were the operating room.
We were able to do bilateral prepector reconstructions with ADM drape.
Um, in a previously radiated right breast.
This patient as well had a right lumpectomy previously, had a right cancer recurrence,
had, uh, and that's her, she didn't want to do anything to the left side.
Again, a pre-pectoral reconstruction in a previously radiated patient.
So obviously I didn't have to be hit over the head more than twice.
Why don't we offer this to all of our patients?
So again, we moved forward and went direct to pre-pectoral direct implant reconstructions in
all patients. These are patients that have had that done and
again you see nice upper pole slopes.
No fat grafting, no revisions.
We published our paper in um in uh February 2020, basically that we're able to do our
reconstruction 97% of our patients, and we also delineated for um.
Easy steps to reproducers and this is kind of where we are now.
A single surgeon, 918 reconstructions, and 508 patients.
This is some of our data.
Basically, um, I think what's important revisions and 8% of the patients fat grafting
and less than 1%.
And defaulting to expanders basically only in 9 patients are less than 1% as well.
Some of the other data points.
Um, I think I'm out of time real quick. She had a right mastectomy reconstruction.
I left augmentation of the recurrence.
We lost the slide. This patient was reconstructed by my partner.
No longer my partner, no longer does reconstruction.
And this is how we reconstructed her as well.
I apologise for running over.
This patient had an expander on the left side. I did 15 years ago.
It was radiated. She came back 10 years later unhappy with their
outcome. I think we're gonna, I apologise,
we're getting the words from above, so thank you very much.
You're welcome. So we move to the next
speaker, uh, Doctor Neil Tanna with robotic assisted deep inferior pigastric perforator
harvest for breast reconstruction.
Hi everyone. Uh, good afternoon.
My name is Neil Tan. I'm a plastic surgeon at Northwell Health.
Uh, we're the largest healthcare system in New York and we're part of the Friedman centre as
well, and it's basically a think tank, you know, we performed the world's most advanced breast
reconstruction, nerve reconstruction, lymphatics, hybrid,
and the latest edition robotics.
None of this would be possible without my colleagues.
Doctor Menassian is here. She'll be presenting,
um, what we consider the next game changer and these two presentations,
this one and the next.
If there's anything that's revolutionised our practise, it's,
it's these two presentations and then, and, and Doctor Mark Smith,
uh, who leads our, our Freedman centre, uh, is here with us as well.
So, uh, with that said, uh, You know, again, this is our team.
We have no disclosures. I was a critic of this.
This is Jesse Selber up there in 2016. I heard him speak at the ASRM and I said this
is nonsense. It's media, it's gimmicky.
It's stupid. It slows me down.
And you know, this 2022, I invited him up to Northwell to do a few cases and I was sold on
it. The deep flap is the gold standard in
microsurgical breast reconstruction. It works well inotic patients for nipple
sparing mastectomy.
It works well in a unilateral reconstruction. I would challenge someone to figure out which
is the cancer breast.
It works well when you have a radiated breasts on the right,
the patient's right side that requires a lot of tissue.
It works well for implant-related complications. This is a stacked deep flap on the left for
capsular contracture.
It works well for implant-related rippling. In our hands,
it is the gold standard for microsurgical breast reconstruction.
In thin women, we find that our hybrid breast reconstruction with deep flaps and implants
is essentially an aesthetic operation and a patient who has BRCA previously augmented wants
to look very similar.
Another patient, also a hybrid breast reconstruction with an implant in place,
and you know we get very nice results at the breast.
What you're going to hear next is a little preview is a hybrid breast reconstruction.
In lieu of the implant, we've been using acellular dermal matrix in the pre-pectoral
position, and that is, you know, really revolutionised our results.
And you'll hear about that in the next presentation.
But the deep flap is not an abdominnoplasty and what we struggle with is how do we make the
abdominal donor sy look as good as the breast, and we've done things like lower the scar,
discontinuous undermining, trunk liposuction, you know,
really trying to work on that. But the problem is,
is there is an inherent hernia rate or more commonly a bulge,
and you can see a patient here that we fixed robotically and you can see the separation of
the rectus without a true hernia, but a bulge. And so while we tout how good we are at the
breast, we really do have to look at the abdomen.
And a conventional open D flap is not an abdominal plasty.
You have these fasciotomies or fascial openings that place the patient at risk of a hernia
bulge or a subjective decrease in their core strength.
And that's what led our group to think what is better out there.
And in select patients, the robotic DFAT makes sense.
So you'll see this term fascia photo, it's a term Jesse Selber and I created and very much
like explant surgeons who provide patients their end block capsulectomy photos,
we provide patients our fascia photos. This is the evidence is here.
I mean, that is an incredible fascial opening, 2.5 centimetres or 3 centimetres.
So what we did was we did our first case in June of 2022.
Kudos to Jesse Selber for coming out and doing the first two cases with us,
and then we, we went off, um, and in, in this seven month period what we reviewed was our
demographics, our characteristics and complications.
A quick note about technique you have to have the right perforator with a short intramuscular
course. You identify the perforator.
These are often single perforator flaps. You get through a small fascial incision.
You get down to the sub muscular space. You place that red vessel loop.
That's key. We keep a second perforator off the lateral row.
We're big fans of MR so we can see which perforator is going to communicate with the
superficial system, and we then keep the flaps perfused and we work on one at a time.
And you know this is basically a short video. Can we just play about 10 seconds of it?
And what happens is you go intraabdominal after you made that short fascial opening,
you're then gonna make a, you're gonna go open the peritoneum inside.
That's the red vessel loop.
You grab the red red vessel loop, that's key. Work with the red vessel loop,
no tension on the vessel. Separate them and you clip it.
Let's move on to the next slide.
Um, you then pull this, uh, pedicle out. Let's go to the next slide.
And you know, let's just play this video real quick.
And if I have to forego my question, I, I, I'm happy to take it at the end,
and here you are, you're pulling the pedicle out.
Through the small fascial opening.
And we'll go to the next slide.
So 17 patients, what we learned is that you know, the anatomy is not symmetric.
You can do it at the time of a mastectomy, you can do it delayed.
Um, you know, our fascial length was about 3.7. Our added time to the surgery was 75 minutes,
and we had no donorcy complications and no increased length of stay.
And it, it does increase the operative time. And the argument I would make is that any
fascial preservation technique, whether it's robotic, laparoscopic,
using the right instruments, we now have adopted that.
When we don't have availability to the robot, that's what we do.
We are fast.
We like to do our bilaterals, and that is the problem with the current technology.
The XI forces you to go to serial processing.
This is the paper that's coming out in PRS.
Yeah, so thank you very much and we'll turn it over to the next speaker.
Thank you, thank you again, sorry about that. If you have any questions,
please email me. We apologise for the speed and the pressure,
but we really have to, uh, be on time in 5 minutes.
Thank you. Thank you for staying on time.
Um, our next presenter is Rach Meacion on augmenting the breast reconstruction.
Good afternoon. My name is Raquel Menas or Ray Anna.
I'm the microsurgical fellow at Northwell Health, as was mentioned by Doctor Tanna
working with Doctor Smith and Doctor Tna.
Um, it's my honour to present to you our highPad technique,
um, today. I have no disclosures myself.
So Atalus breast reconstruction offers a very natural looking and feeling result for most
patients, and a lot of patients want this reconstruction, but there's a subgroup who
don't have enough tissue at the donor site area.
So for these patients, there's a variety of techniques we can use to augment the free flap
reconstruction, such as fat grafting into the flap or into surrounding tissues,
um, and using alternative or stacked flaps as well as hybrid techniques.
Hybrid technique is traditionally described as the addition of a pre-pectoral implant placed
at the same time as the free flap, excuse me, reconstruction.
In our practise we've modified this and created two new techniques that build upon this um that
we've found very successful so far.
The first just briefly mentioned is a high fill technique where we at the same time as a hybrid
reconstruction with an implant, we simultaneously lipofill both the flap as well
as deep into the pectoralis muscle muscle, uh, major muscles,
excuse me. And then the high pad is the second technique
that we is the focus of my talk today.
So HIPA stands for hybrid prepectoral acellular dermal matrix.
So as you can see, different from traditional hybrid technique,
there's no implant here. So we rely completely on the ADM construct that
we create and place in the same prepectoral plane deep to the free flat.
This is a great option for the growing community of patients who is very averse to
implants and wants to avoid that completely.
These patients have a variety of reasons for this, be it BII or the rare breast implant
associated cancers such as ALCL or squamous cell carcinomas,
as well as implants specific complications like apsular contracture,
rupture rippling.
Um, or there are some who just don't want to have to go through the monitoring with imaging
over time or have to have these maintenance procedures later in life.
They want to be done with their cancer reconstruction.
So we followed a series of patients over 17 months.
All of them lacked adequate donor sight but wanted autologous reconstruction without an
implant. So we performed this technique and we tried to
quantify our results by measuring the intraoperative weights.
So here you can see our ADM construct, originally designed more rectangular in shape,
but we've since revised and refined that to be more circular in shape,
similar to a small implant as you can see on the far right.
And we can achieve about 2 centimetres of projection, and we've achieved up to 140 ccs of
volume. So we prefer to use an extra, extra thick
alloderm for this. It's a sheet of 16 by 20 centimetres that's
folded upon itself and secured with PDS sutures at multiple levels.
That keeps the contract construct nice and compact so that there's no dead space.
The ADM is first inset into the breast pocket in the photo on the left,
and that's secured along the breast meridian, abutting the IMF.
And then the free flops brought into play.
Anastomosis performed, and it's inset very, very carefully to make sure the entire ADM
construct is covered.
And here at 3 months post-op around that time, most patients get a revision to remove the skin
paddle or do other small nips and tucks. Um, and you can see here we've elevated the
flap and zoomed in on the right. The ADM construct can be visualised nicely
incorporated against the chest wall, not moving, not going anywhere,
and with a vascularized but thin membrane overlying the superficial surface.
So our study included 21 patients, on average about 49 years old with a BMI of 24.
And then you can see the mean inoperative weights, the mastectomy specimen about 430
grammes, the flap 370 grammes, and that's about a 14% discordance between the two.
The alloderm that we created on average weighs about 83 grammes,
and this supplied 17% of the total breast reconstructed volume.
And while we were trying to focus on quantification of results here,
um, just to be fully transparent about things, we have had one complication with using this
technique. There was a patient who developed a hematoma
who had required evacuation postoperatively that led to subsequent mastectomy,
flap necrosis, and delayed wound healing in an area.
Eventually that kind of declared itself as a sinus tract that tracked to the ADM,
so that was excised the tract itself and the ADM removed unilaterally.
No other complications have been reported though, no seromas,
and we do, I should have mentioned, place one drain at the time of the high pod
reconstruction.
So in conclusion, it's a great option for patients who are looking for a hyroidattologous
reconstruction but really want to avoid an implant.
In these patients with a relatively modest discordance between their breast size and donor
site, it's something to be considered to add both volume and core projection.
Thank you so much. Thank you and thank
you to stay on time because me and Era really hate to catch you all guys.
We don't enjoy it, I promise. Any questions from the audience?
No. Then the next speaker is Alex Margulis, uh,
reconstruction of severely burned breast.
So, good day. My name is Alex.
I'm from Jerusalem. We're gonna change the subject a little bit and
speak about reconstruction of the severely burned breast.
So, I have no conflict of interest.
So chest wall burns are common in children. They pose aesthetic and reconstructive
challenges, and of course they influence the breast shape and development,
and usually they are not confined to the breast alone.
So let's take a look on the difference between our cancer patient and the burn patients.
So in the cancer patient, you need to reject tissue, whereas in the burn patient you need to
preserve tissue. Cancer patients, the defect is confined to the
breast, whereas in the brain it's almost never confined to the breast.
In cancer patients you need to reconstruct only the breast,
but here you also need to reconstruct the surrounding the chest and abdominal wall.
In a cancer patient you have multiple available donor site,
whereas in the burn patient.
The donor sites are either burnt or simply not enough tissue there,
and of course there's a sudden psychological impact, whereas in the burned patients they are
dealing with many years with the deformity and potential loss of femininity.
So the classic approach, kind of the gold standard, it's like let's wait and see what's
going to happen when the child gets older, and some of the authors advocate release surgery,
but this release surgery leave you with big defects, and they are usually covered with skin
graft, and this just cause additional scarring and high incidence of reconstruction.
Then of course LED flaps were very popular because they're usually out of the burns side
and also some of the authors authorised deep flaps, but of course many of those patients
have just insufficient abdominal laxity but simply not enough tissue for variable breast
reconstruction and also of course the abdominal area is often included in the.
So this is our patient that we had treated 70 patients with severe scarring of the breast,
and you can see the data here.
So our approach is a two-stage approach. The first approach,
the first stage, we do extensive resurfacing, unique flap using flap-based reconstruction
with expand the flap during which we evaluate the existing breast volume,
preserve the existing breast volume, and mobilise the map positional complex,
and this. When we can, we do it early, and this is an
example. You can see this little girl, you see the
nipple is very well positioned, and this is the first stage we can do it early because we
believe that the breast will develop better underneath those ultra thin flaps than it would
develop under this thick and feathering scar.
Then the second stage is implant reconstruction. We do it with puberty and then we do the
symmetry procedure to the other side. You can see this is the resurfacing,
and then in the second stage we do breast augmentation.
So just do this shortage of time.
I'm going to use this patient to demonstrate our approach.
So this is a 21 year old patient and you can see no point in waiting because the breast will
not develop. You can see the malposition nipple.
So this is the first stage where we surface. Everything with thin expanded flap,
we preserve the original nipple even though it looks sometimes very bad,
but after you release it from the scar, it will surprise you.
And after doing this entire set of scar excision and reconstruction of
the entire area, not only the breast, but also the chest wall and the abdomen.
Then in the second stage we do the breast augmentation and reconstruction,
and this is her result.
This is another patient, same principle.
So of course we had complications. They are rare.
We had exposure expanders. We had some residual asymmetries like in this
patient, of course you will have to have some more fat grafting,
etc. and then of course hypertrophic scars are not
uncommon because we're dealing with chest wall.
So to summary, our resurface area as part of the chest wall and abdominal wall construction.
The tethering constricting scar will not promote growth,
so there's no reason to wait.
The breast tissue is often there.
We can preserve it, and then nipple complex could be preserved and should be preserved and
mobilised to a better location, and it can surprise you.
And then of course in the second stage breast reconstruction prosthesis combined with canola
augmentation help to achieve symmetry and more pleasing breasts,
and longer follow up of course is still needed for many of these patients,
many of them will reach mature breast growth in the future.
So this is our medical centre in Jerusalem, and you are all welcome to come and visit our quiet
and peaceful city where nothing ever happens.
Thank you so much.
Uh, questions from the audience?
I have a question.
How patients tolerate the tissue expander? I, at least if I saw,
well, they have you position also some tissue expander on the belly without any very hard
surface behind.
Well, you have some tips or tricks for that?
This is an excellent question. We actually do not use expanders with a hard
surface. We use expanders with the soft surface,
and actually it's very well tolerated in all ages, but especially in children,
most of them get an expansion outwards without pushing on the belly.
and it really gives you very nice and ultra thin flaps that you can use,
and uh we've seen that even if you use it in childhood.
Then you still get a nicer breast development under those flaps in comparison to
the those heavy and tethering scars.
Thank you very much.
Our next presentation is from Yun Bee Kim, comparison of conventional versus robotic
assisted immediate implant-based anattologous breast reconstructions.
OK, hello, my name is Yung Bee Kim from Assam Medical centre or South Korea.
So it's really an honour to have a presentation in this great meeting.
So I want to introduce our study about comparison of conventional versus global
assisted breast reconstruction.
I'm the disclosure. And since, uh, uh,
introducing robotocystic mastectomy and breast reconstruction in 2017,
several, uh, studies reported about some techniques about the robot assisted breast
reconstruction, but there's a lack of reports that compares uh conventional versus robot
assist surgeries, so.
In our centre, we do robot systematectomy by breast surgeon and plastic surgeon to the
reconstruction using implant and also uh abdominal-based reconstruction.
So the aim of this study is to compare the immediate conventional versus robois mastectomy
and breast reconstruction.
So the demographic data we included 423 conventional and 153
robotoxy patients were included both implant and abdominal flat patient.
Uh, demographic data shows that higher BMI and higher cancer stage and higher radiation
history in conventional groups and other vas are comparable.
So, uh, uh, roboy group has more uh liposparum mastectomy compared to conventional group and
in uh incisions were later explain incisions to uh robot.
And total operation time was higher in robot's group.
It was 40 to 50 minutes, and the only uh recipient vessel used in the robot was the drug
dozer vessels.
For the reconstructive outcomes, uh, for implant-based reconstruction,
uh, there was lower skin necrosis requiring surgical developments as shown in robot
assististic group. Other complications were comparable in
abdominal flat faces reconstruction, there was no difference between complications.
Uh, we did, uh, PROMs using rescue scores, uh, in implant-based reconstruction,
sexual well-being score was high on global assist group.
Other scores were comparable in abdominal flat-based reconstruction,
the physical wellbeing score was significantly higher in robot assisted group.
And also we did a multi-varied linear regression to controlling factors.
Uh, after controlling factors, the actual revolving scores and physical we scores were
significantly or near significantly higher.
I will show you a short video to to show uh presentation time.
This is the docking of the WSP model. We can switch the ADM to the chest wall using
rubbert, and also we can repair the IMF with fixating the ADM in implant-based
reconstruction. In DF flap, we can sing the flap to the chess
wall for flap in setting.
So I want to show you some cases of roboc implant-based reconstruction.
This patient had prepector plane 230 cc of some surround implant.
We can see the scar is not visible in the front view.
We can see small little incision here.
Uh, for the DF flap, this patient has a DF flap in the right breast.
As we can see, scar is not visible in the front view.
We can see small lateral excellent incision in the view.
So, uh, many of the uh surgeons using robots for breast reconstruction in various regions,
uh, our study focused on the area of the mastectomy.
We could, we could light a scar and visible in first view.
And this issue away from the mastectum flap could preserve to continue with the subdermal
plexus, so we can reduce the skin necrosis.
And also rescue comparison shows higher sexual well-being and higher physical well-being
scores. So robotic surgeries uh shows lower skin
necrosis and better patient reported outcome, and robot surgery could be a good option for
mastectomy and breast reconstruction.
Thank you for listening. Do you have
any questions from the audience?
I have a quick question. Great presentation.
Do you have certain indications now, or I guess more contraindications for robot assisted
things that might make it more challenging, whether it's breast size,
ptosis. As indications may be planned to have a nipple
mastectomy and have some quite small breasts, but usually Asian Korean
patients have lower BMI, so maybe most of the patients are in indication.
Thank you. And So the next speaker
is Sarah Loni with uh an algorithm for regional correction of mild tuberous breast deformity
in breast augmentation.
Thank you. So good afternoon, I'm Sarah Loney from Sydney,
Australia, and I'm talking about our algorithm for regional correction of mild tuberous breast
deformity in breast augmentation.
No disclosures.
So tuberous breast is traditionally classified in 3 or 4 grades,
however, it's truly a spectrum of severity, and patients may present with subtle variations of
the deformity. Up to 50% of mild tuberous cases may present
for breast augmentation, and these, uh, this deformity needs to be identified to avoid
exaggeration of it when augmentation is performed.
We've developed a stepwise algorithm for managing these regional abnormalities in milder
tuberous breast deformity cases.
So the first key step with the tuberous patients to identify whether they can be
managed in one or two stages.
So, uh, we prefer to manage these more severe cases with marked glandulitosis,
moderate to severe asymmetry, and marked macro areola as two stages.
So then the patients that you determine you can manage as one stage,
the next step is to examine for glandulitosis, um, if there,
and then if there's any change with the inffra mammary fold with um elevation,
whether it effaces or whether it doesn't efface, uh, the degree of constriction of the lower
breast pole and then the degree of nipple areolar complex herniation.
And then the severity of each of these uh regional regional problems determines whether
it's simply mild and can be camouflaged or need is more severe and needs to be uh corrected.
So, uh, our key steps, so implant and pocket selection, we prefer to use an inframammary
fold incision, uh, a hydropla sub pectoral pocket, except in patients who have a very well
indented inframammary fold.
If they have at least 2 centimetres of skin pinched thickness,
we would do a subglandular plane in order to try and reduce double bubble,
and then anatomical implants to expand the lower pole.
In considering each region, so firstly the inframammary fold,
incisions at 7.5 to 8.5 centimetres depending on the uh implant size.
And if the IMF is not visible or completely effaces with arm elevation,
it can simply be camouflaged as shown here with fat grafting.
And we do that when the size is in place.
If the inframammary fold does interface with arm elevation,
then we do an effacement flap, which is uh from the superior portion of the incision,
a 2 centimetre superiorly based fascial flap, um, to release that fascia and then be able to
be a small flap that it can control the IMF as with a 3 point suture.
It also allows for scoring of the lateral tuberous bands.
And then uh if there's any residual indentation where the fascial adherence of that old IMF was,
we'll inject that with nano fat.
In considering the lower breast pole, in cases of mild constriction we simply fat graft,
but in cases of more severe lower pole constriction and where there's excessive excess
upper pole glandular tissue after placing the implant from the.
Incision. We then do a periareolar incision,
preserving a superior pedicle and at least 2 centimetres of glandular tissue deep to the
nipple, then divide that upper pole tissue in the coronal plane to be able to
distribute that upper pole tissue into a pocket that we make in the lower pole.
In terms of addressing the nipple areola complex herniation,
camouflaging can be better in a younger patient as it buys time um for future changes with
breastfeeding or pregnancy and is less invasive.
So our technique for camouflaging the herniation, we call popcorning,
which is um a Colorado needle tip diathermy on spray 20 inserted into the four quadrants of
the nipple after the implant's been placed, um, and then this results in constriction.
It can be a residual indentation um between the nipple and the breast,
and then we inject that with nano fat.
And in cases of severe nipplearial or complex uh herniation,
we perform a periareolar mastopexy.
So we audited 5 years of uh of cases that of patients who presented with early stage
tuberous breast deformities and undergoing single stage correction and augmentation.
And there were 142 patients and mostly, as you can see here,
dual plane augmentation, the IMF mostly addressed with nanofa grafting,
pop corning of the nipple areola complex and fat grafting to the lower breast pole.
There were no early complications, but 4.2% of patients had revisions for uh late
complications. Says to show some of the results here,
says this 20 year old girl underwent dual plane augmentation uh with anatomical implants.
On the right, she had a tuberroexy flap to distribute that upper pole tissue and left
perial mastopexy and IMF effacement flap and fat grafting to the cleavage.
Then this 19 year old girl underwent hydroplane augmentation with asymmetrical implants,
pop corning and nanofa grafting to the nipple areola complexes,
and fat grafting to the lower breast, the lower breast pole and the right IMF.
So in conclusion, so important to address the um each anatomical area and determine whether
it's mild uh or moderate severity to be able to address this,
um, to improve and optimise aesthetic outcomes in breast augmentation.
Thank you.
I think we'll skip questions and you will hang around for one more.
Um, Sarah's going to be presenting again on novel technique for management of breaststria
dysteni and aesthetic surgery.
OK, yeah, so my next talk is so our novel technique for management of breast rea in
aesthetic surgery. So stria distends a uh a dermal scar and it's
often associated with weight change or pregnancy and results from the mechanical
stretch of skin that disrupts dermal collagen and elastin fibres.
The main problem of stria for plastic surgeons is in patients who want to undergo breast
augmentation, mastopex, Eurovision.
So it worsens the aesthetic outcome and it puts patients at risk of functional complications
such as premature glandulitosis, um, or relapse as they have weaker dermal support around the
implant. And no technique has been described for
management of pre-existing StriA in uh breast surgery patients.
The technique that we or the algorithm that we've developed is for patients with breast re
presenting for augmentation or mastopexy with Fitzpatrick type 1 to 3 skin,
undergo nano fat grafting at the time of surgery, and then uh postoperatively carbon
dioxide laser. For patients of Fitzpatrick 4 to 6 uh skin type,
they undergo nanofa grafting alone to avoid hyperpigmentation from the laser.
So a technique for nano fat grafting, firstly, the fat's harvested usually from bilateral
thighs after um infiltration, then centrifuged and then the lipo aspirates emulsified,
um, then following at the end of surgery, so following the mastopexy implant placement,
intradermal injection of the nano fat is done with an 18 gauge blunt fill needle.
So firstly rigotomy and then on withdrawal, the, the fat's injected and usually around 5 to 10
cc is required per breast.
And the our protocol for laser is that it's commenced once the patient's fully healed,
so usually 6 to 9 weeks post-operatively, uh.
We ask patients to apply a compound cream of hydroquinone tranexamic acid and ascorbic acid
for 2 weeks uh pre-treatment for 3 times a week, and recommence this 2 weeks after treatment
to reduce hyperpigmentation.
Then fractionated CO2 laser is done with a single pass of a DFX laser,
um, with the pattern depending on the area of stray.
Patients expect scabbing and erythema for up to about 1 week and then during that time apply a
cool compress or V and Vaseline 5 times a day and uh uh to avoid sun exposure for 4 to 6
weeks. You've required a second session of laser may
be performed, um, it's 6 months following the first.
So we've treated around 20 patients with this technique, um,
the early problem was mostly hyperpigmentation, and so to avoid that,
um, we changed the laser treatment from being two passes of,
um, what is described as an active FX laser, which is a wider,
more superficial laser, um, and DFX, which is the more deeper,
uh, laser that targets in dermis, which is what we're aiming for with SRA.
Um, so now use the DFX alone and then if required a second session at 6 months.
So the rationale behind this treatment is considering stria as a form of deep scar.
So nano fat grafting has been used previously for facial scars,
rights, and skin discoloration for the benefits of a small volume of intradermal filling,
the ergotomy, and the stem cells it provides. So these growth factors may be stimulating
tissue regeneration, improving collagen and elastin synthesis.
And the laser treatment similarly is used um as with scarring,
so for skin resurfacing and to promote collagen formation and reorganisation of the elastin to
contract. So fractional carbon dioxide has been used
elsewhere in the body for for otherstria, um, there's only one paper that's previously
described using laser for breast 3A, which was a group that used herbium following uh breast
augmentation. However, they found that they had variable
results of the success of this, and herbium's a more superficial laser,
um which has the benefit of less of faster healing and less hyperpigmentation.
However, it doesn't then target that deeper dermis, and so a subsequent systematic review
and metre analysis of stria elsewhere on the body being treated with laser has found that
carbon dioxide is better than other forms in terms of effectiveness,
patient satisfaction with no increase in hyperpigmentation, presumably because it
importantly targets that Depodermis to titan collagen.
So in conclusion, this is the first technique described for management of uh pre-existing
breast reA in patients. It's important to address these to be able to
optimise aesthetic outcomes and reduce the complications such as worsening of the SRA for
scarring and ptosis.
Thank you. Thank you very much.
We move to the next speaker, uh, Doctor Emma Hanson.
5 year comparison of biological and synthetic meshes in breast reconstruction.
Good afternoon. Thank you for the opportunity to present our
research. Uh, we've, uh, performed a study where we
randomised patients that are having bilateral risk reducing mastectomies and immediate breast
reconstructions to a synthetic mesh on one side and a biological mesh or matrix on the other
side. The aim was to compare the biological mesh with
the synthetic mesh and implant-based breast reconstruction in the same patient with respect
to complication and correction frequencies and patient satisfaction with a 5 year follow up.
We randomised 48 breasts, um.
24 breasts in each group were available for long term follow up regarding complications and
corrections, and 19 regarding quality of life.
The surgical techniques were identical on the on both sides.
Uh, the same breast surgeon performed the mastectomies and the same plastic surgeon
performed um the reconstruction on both sides.
The two meshes used were Veritas and Tiger, both resolvable meshes.
Not going to present any demography demographics, of course,
because they were identical in the two groups, perfectly matched regarding drain production,
it was quite similar in the two breasts.
We used continuous infusion of local anaesthetics the first day that's why it's
bigger initially.
Uh, regarding seroma formation of the drain removal, uh,
we saw, we saw a higher frequency in the biological group.
Regarding complications, there were more expander and implant losses in this biological
group than in the synthetic.
An 8.4% frequency compared to 2% in a synthetic group.
Regarding corrections, um, there were more corrections in the biological group,
uh, in the patients that lost implants, they were later re-reconstructed with a new expander
and later an implant.
And most of the corrections were done in that group.
It was difficult to compare satisfaction as there's no validated instrument that allows
comparison of the right and left breasts in the same patient.
So what we did was use individual items in the rescue domain satisfaction with
breasts. So the patients scored different aspects on a
scale from 1 to 41 time for the right breast and 1 time for the left breast.
And as you can see, there's no one mesh or ADM does not seem to be superior to the other
regarding patient related factors.
If we look at scores between the groups, more than half of the patients were actually equally
satisfied with most aspects of the breasts.
The patient seemed to be more satisfied with the synthetic side regarding uh size of the
breast in a bra.
And uh feel to touch, whereas they were more satisfied in the biological group uh
regarding uh shape without a bra, natural appearance and appearance compared to
preoperatively. Uh, so in conclusion, there were more
complications and corrections in the biological mesh group.
One mesh does not seem to be superior to the other regarding patient satisfaction,
but the measures might give rise to different morphological effects which we could use
when we tailor breast reconstructions to individual patients.
Thank you. Thank you very much.
Any question from the audience?
I have a quick question for you.
Um, do you have any case when you are, you have a tissue expander and you have to change it
with an implant, when you have to low down, for example, a little bit,
the infra mammary fold or whatever, what is your experience with autologous and
synthetic? Uh, there are, uh, more seroma and more fluid
in the biological group, definitely. OK.
Thank you very much. Thank you.
We have one more presentation to go.
A quick reminder to please scan the QR codes. You can vote at any time.
The final prize is for a 1000 pound travel grant sponsored by LBM,
so we do encourage everyone to apply next year as well.
With that, we'll go on to our last presentation by Marcos Antonopoulos minimising animation
deformity using selective denervation of the pectoralis major muscle.
Thank you. Hello, my name is Marcus Antonopoulos,
and I'm a junior plastic surgery trainee and a PhD candidate from Greece,
and I'm here to talk to you about our experience with minimising animation deformity
with the use of selective nervation of pectoralis major muscle in
subpectoral implant-based breast surgery.
As it's widely accepted, sub pectoral breast implant placement can have many drawbacks,
mainly due to the contraction of pectoralis major muscle,
which can create animation skin deformity, as you can see in the video.
Selectively denervating the sternal and coastal muscle segments is a technique which can reduce
animation and through our experience of nearly 130 cases,
I'll present to you a prospective study.
In which 10 unilateral and 10 bilateral implant-based operations were performed with
pectoralis major selective nervation in a period of 6 months,
as well as dynamic evaluation of muscle strength using a digital dynamometer.
During the operation, the dissection to create the implant pocket was superiorly extended to
identify the lateral pectoral nerve along the thoracoachromal vessels,
as well as the medial pectoral nerve nerve arising through pectoralis minor and then.
pectoralis major on its lateral border.
Further verification of the external and coastal muscle segments was achieved using a
nerve stimulator as a way to exclude the branch that innervates the clavicular segment,
as you can see in this video, which is without muscle relaxant.
And then the nerves were cut superficially to the muscle,
as well as an approximately 1 centimetre nerve segment removed from each branch as a way
to not reinnervate in the future.
The partially denervated vascularized pocket acts as a cover for the implant without any of
the muscle contraction skin deformities, and pre-opened post-op pectoralis major strength
evaluation with a digital dynamometer, as you can see in the video,
was achieved as an objective way to confirm the successful selective denervation and not
complete loss of muscle function, which would be a result of total denervation of the muscle.
All of our patients recovered well. There was a 100% satisfaction with the
aesthetic result, and during the 6 month follow up, none to mild animation deformity was
observed at full flexion of pectoralis major.
There was no loss of upper extremity functionality reported or any weakness in
everyday activities.
And the strength was evaluated at full flexion, pre-op and post-op with the use of a digital
dynamometer, and the results showed partial loss of pectoralis major strength,
which was then regarded as an indicator of a successful selective derivation of the muscle
segments involved in the skin deformities which I mentioned before.
These are some of our unilateral results. On the right,
you can see a complex case which is right breast, sub pectoral reconstruction,
post radiotherapy, as well as left prophylactic mastectomy with pre-E reconstruction for
symmetry. As you can see, there's no animation deformity.
There is a very good symmetry on the left. There is no animation deformity as well.
This is one stage reconstruction. At the bottom of the slide,
you can see the dynamometer measurements uh comparing the site which was denervated against
the normal one, showing the difference in muscle force.
And these are some of our bilateral results. On the left you can see a mild animation
deformity. On the right there is no animation deformity,
and again at the bottom of the slide you can see the dynamic evaluation.
On the left is the chart showing pre-op measurements.
On the right it's 6 months post-op, showing the difference of muscle strength after the
selective nervation, which rough rough data, it shows to be about 40 to 60%.
As a conclusion, selectively denervating pectoralis major is a safe and viable addition
to submuscular implant placement and can be a solution to minimise animation deformity.
With this technique, there is no loss of shoulder functionality or mobility affecting
everyday activities, and it is a technique which can be used both in reconstructive.
Well as aesthetic cases as in this case, which is bilateral sub pectoral breast augmentation
with bilateral selective derivation of pectoralis major on the left it's pre-op on the
right it's 6 months post op showing no animation deformity again with the objective
way to confirm the the the selective derivation with the measurements.
And as a final slide, I would like to leave you with this video,
which is one of our very early cases, bilateral subpectoral reconstruction,
but we only denervated the right side and as you can see,
selectively denervating pectoralis major is a safe way to actively combat animation deformity
in sub pectoral implant-based surgery.
Thank you very much.
Thank you very much. So please, all the audience vote because one of
uh those fantastic speakers will win the travel grant offered by LBM.
1000 pounds. So thank you very much.
And apply next year, every one of you.
Yeah.
Another 30 seconds or so, although it looks like we're trending in a specific direction.
OK, I think she's. OK.
So it really seems that the winner is Alex Marulli, reconstruction of severely burned
breast. So please come.
Mhm. Doctor Maliy will give you the prize.
And thank you