Alright, uh, good afternoon, everybody.
um, I think we'll go ahead and start a minute earlier we have a great panel,
um, on, uh, innovation and technology and hopefully we'll,
we'll be able to learn some new tricks, uh, for the treatment process,
um, JP Hong and.
OK, great, and we have 3 panellists, and I think we'll go ahead with all 3,
talks and then hopefully have time for small discussion at the end of all 3 talks.
So without further ado, Andrea not introduced the first uh author,
I mean the first presenter.
Very excited.
To see uh Benjamin Safati again, um, and he's going to talk about robotic mastectomies.
Hello everyone. I want to thank first Marlen and Jen for the
invitation. Really pleasure to be here as usual.
And uh thanks for inviting me to speak about something I really love,
but I have to say now I'm in trouble and I will tell you why at the end of this lecture.
So for sure when you have a new idea in a surgery before you do your first case,
sometimes it will take a long time. It's like a long walk alone in the desert and
sometimes your colleagues just want to kill you and kill your project before you do the first
case and there are some some of them still wants to kill and but some of them want to be
trained on on the robot.
So when you have a new idea.
The ideal thing is to improve the quality of life for the patient and at the same time,
if you can decrease the rate of complication, it could be a good idea and we know that since
30 years, one of the most important revolution in surgery was the venue of laparoscopic
surgery. It changed everything.
If you ask the general surgeon why you don't do a big scar on the abdomen instead of a
laparoscopic surgery, you will say you're crazy.
So we know that with this kind of surgery, we have less pain,
less infection and shorter recovery.
So the question is why we don't apply this principle to the breast.
We are very lucky because in November 2014, a Swiss bank give us for free to Gustav
Rossi, the da Vinci Xile.
As a plastic surgeon, we are very, very happy, very excited to have it,
but we have no idea at all what we can do with that.
But the big boss of Gusta Rossi told us, OK guys, you have the robot one day per week.
Thank you very much. But we don't know at all what we can do with
that. And having a robot is good, but if you use the
robot and it's more and less efficient that you can do with your own hands,
it's totally unuseful.
So before you do your first patient, it's a good idea to go to the anatomic lab to check
out because at this time nobody used a robot. Nobody has done the robot on the on the breast.
So you have to imagine everything where to put the robot,
where to put the nurse.
So we go to the anatomic lab and sacrifice one of the fellow before the first case to
be sure that we will be ready for the first cases.
You have to know that you are not alone on this. You have to convince the nurse,
you convince the anesthesiologist, your colleagues, they will see after,
but you have to be ready for the first patient.
The idea is quite simple.
It's to change this kind of scar on the breast, lateral side of the breast or in front of my
fall. To a shorter scar, not on the breast, not on
the lateral part of the breast, but far from the breast.
7 centimetres posterior to the lateral part of the breast or under the arm is the patient has
a breast cancer. Just a short video to to show you.
So we do uh to infiltration with the saline serum and epinephrine,
and I do all the superficial undermining with a scissor.
I go as far as I can with that to undermine the wall gland.
This is one old videos, so I usetapler, but now I use the JPoint Mini.
I will show you at the end and we use only 3 roa.
We have a laser cross to localise where to put the robot,
and you have to stretch the skin to work above the plane of the breast.
After that, you willlate with CO2 and you do breast mutation with hair.
It could be fancy one day maybe, and we put the camera inside.
After that you have all the place to do the prepectoral dissection to finish the
superficial dissection and as you can see with the slation,
we see very well the plane with the the direct crest also,
so it's very easy.
You are totally inside the breast.
You see much better than when you do for incision through small incision.
So you continue the superficial dissection.
You can, you can go behind the nipple.
You try to reach all the bone margin of the breast.
And It's quite easy. The robot doesn't take any decision.
It just reproduces the movement you've done on the console.
But it's difficult when you start the surgery to know which quadrant you are in the breast.
So you need the assistant to tell you, OK, you are in the upper cresant,
and you touch the skin and and you see it with the camera.
If you need to do retrone biopsy, you can do it with a robot.
After that, you do the prepector dissection and it's quite easy because of the inflation.
We see the plan very, very well.
And we finish the second land like this and we detach the at the end the lateral attachment of
the gland. After that we remove it through 4 centimetre
scars and you put the implant in a classical way without any idiom or meshes.
Why? Because. The quality of the skin is good enough to
support the weight of the implant.
You didn't cut the fold. You have done nothing,
so it's strong enough.
I tried everything to put mesh inside to put ADM to fix it with the robot,
but I have to say we just put the implant under the skin.
The skin envelope is very strong and strong enough to support the weight of the implants.
So what is the perfect education? is this kind of patient without any good
definition of the femary fold, small breast. We know that even if we put the scar in the
femary fold, it will be visible.
We can do that also for bigger breasts and also for bigger breasts we can go until cup C.
Just if you don't need to reduce the skin envelope, you can do robotic surgery.
So we have to know that we don't have the the the approval for that,
and but we have the C marking for prophylactic surgery for the XI and for the new robot single
port, we have the C marking for cancer surgery and prophylactic.
OK, you will tell me, OK, you're, you're a nice guy.
You, you, you, you, you are convinced, but what the data say?
I, we have to, I have to say now we have a lot of um of of study now,
especially from from the ASEAN country and.
We have a lot of data about this first about the safety and if your search is published.
Until now, but we don't have a very long term follow up.
The maximum is between 5 to 8 years.
We don't have increased recurrence in the group of of of robotic surgery,
and it's normal because you are very precise.
you are inside the breast, impossible to see as well when when you go through the randomary
fold. What we want, what we show also is we do a
comparative study. It was done by my friend Antonio Teska.
It was a prospective study and he he did a breast cue for open surgery compared to robotic
surgery. Robotic surgery has better results with sex
with the breast and the sexual wellbeing.
And this is right. When you ask the patient,
you have the choice to put a scar on the breast or you have the choice to put the scar under
the arm. She would pick the scar under the arm,
100%. The idea also is to prove that we have less
infection today we don't have the data for that.
The idea is we have no contact between the implant and the scar because the scar is very
far from the breast. So in case of with the incense,
we have no risk of implant exposure, but now the data didn't show it yet yet.
But the data show that we have less grade 3 complication, less nippo necrosis,
and why we have less nippo necrosis, because we don't use any retractors.
We use only deflation.
It's, it is much softer than the retraction of of that of your assistant and also because we
keep all the skin envelope, we don't get any dermal plexus,
so you have all the skin envelope to vascularize the complex and you have also less
blood loss and everything is published now for sure, if you use a robot,
it will take more time.
I have to say, since uh from skin to skin it it took me between 1 hour to 2 hours,
including the breast reconstruction, so not so, so big things.
And and I think it will be the game changer for all minimally invasive breast surgery and
Deborafa from Dallas is starting.
A positive about that. The first results show that we may have a
better sensitivity on the nipple and on the breast with this kind of surgery.
Why? Because we use slation.
It's very soft for the tissue and also because we don't put a very long scar in the ham,
so we keep all the superficial nerves from the skin to the nippo complex and for sure we'll
say who will pay for that.
Right, but in neurologic surgery, in abdomen surgery, in gene surgery,
they find a way to to to to pay for that. So if we can prove that with that we have
better satisfaction, less complication, this is our duty to,
to show them that we will save money with this kind of surgery.
And the extra cost for the surgery it depends on your hospital and your country.
In Italy it's for €4000. Taiwan for $4000.
In France it's cheaper.
We always, we're always cheaper surgeon.
So for sure we have an extra cost, but this is our duty to prove that it it
it it's worth it.
For sure the the future of the surgery is the single port now it is available in Europe and
we have seen marking for prophylactic surgery and for breast cancer and we can do everything
through on on only only one scar.
Just to show you some results, this patient has a BRCA mutation.
She wants a bilateral mastectomy, but she was afraid she was afraid of the scar,
so she waited 10 years before doing the surgery, but now we have the scar on the other hand,
so she, she's ready for that.
This is the result just after the surgery, after 3 months,
so we see the ripping effect, right? because we put the implant under the skin above
the muscle, but we, we, we know how to manage that.
So we, we, we see the, the wrinkles of, of the implants, but after one session of fat grafting
between the capsular and the skin, we can achieve quite good results with a small scar
under the footprint of the bra.
So for, for prophylaxis surgery, we use this scar but now we do it horizontally,
but we try to hide it under the bra. But for coer patients,
we do everything from uh the the axilla.
And you have a new robot, new toy, you want to play or,
so you go back to the anatomy club and you try to do mastectomy through Zombilicus is
published also in PRS now and I have to say it's quite easy on the cadaver for sure,
but it can be a good indication for gynecomastia if the patient doesn't want this
kind of breast, so we can reach the breast, remove the gland.
And why not put an inflated implant inside?
So for sure you can say everything robot we can do the same,
but robotic surgery and technology is the future.
If you don't let the technology come in the OR, you will be outated very,
very soon.
But as I said now, I'm, I am in big trouble because I do also endoscopic surgery and
we do with the same incision and what is good with endoscopic surgery is.
We have AD approval and the approval, so we can do that for prophylactic and cancer surgery.
For sure it's cheaper.
We have a tactile feedback so we can, you, you can feel exactly where we are because in the
robots you can go through the skin without feeling it.
And for the training, everybody has a laparoscopic in the hospital or in his clinic,
so you can start tomorrow.
So I was very stressed and I'm gonna organise in June the first master class in robotic
endoscopic surgery and I invited, I invited all the international specialists in endoscopic and
robotic surgery, and the conclusion was simple.
We have exactly the same medication, exactly the same scar,
and exactly the same results.
With endoscopic and robot, but we are a little bit less comfortable with endoscopic surgery
and for sure robotic is more fancy.
But I have to say if the patient come to say, OK, do you prefer me to do endoscopic or
robotic, it will be difficult to to to to tell her she will she will have to pay more for the
same surgery. So we are just as busy being at the new era of
surgery. Of breast surgery, you have minimally invasive
breast surgery. I invite you to come in Paris in June to speak
about that endoscopic robotic, but also breast cancer surgery under local anaesthesia.
We can do now mastectomy and breast reconstruction at the local anaesthesia and
also for aesthetic surgery.
So please, you are all welcome in Paris and what is good is you can just put an Eiffel
tower and I'm sure that everybody will come.
Thank you very much. Thank you, Benjamin.
All right, so I would like to call about the Lapina to talk about the use of PRP in
breast surgery.
I don't think that's it. I think you're gonna talk about radio frequency.
Uh, well, actually I'm, I'm gonna speak it was uh uh mixed up on the on the on
the schedule, but I mean it was corrected on the on the internet.
Well, as this is gonna. Be my last presentation in this London press
meeting I would like to tell you that I really feel honoured to be part of the faculty here at
the London press meeting, and it's great to have all this friendship and,
uh, sharing of knowledge with a very high scientific level.
And uh well one of the best definitions from art that I've
seen comes from Aristotle as he was saying that art is the possibility to see the end
result before you start transformation.
And with this it means that the artist must have the skills to get that result that he has
in mind and I think that we as plastic surgeon has to do exactly the same we've got to see the
end result before we start doing it.
And basically uh we have started this project of doing a breast reduction with
no scars uh 10 years ago and.
How do we can achieve this because we all know what happened with the breast reductions a lot
of times we know that this surgery had a very high rate of complications that can come
from a simple uh sterile inflammatory process or we can also
have a lot of breast, uh, fat necrosis that end up with all these factors.
So, uh, here sorry I couldn't, uh.
Translate this slide, but on the first three, layers of the of
the slide, it says the amount of fat necrosis that we can get in gigantomasia,
moderate hypertrophic, and the standard breast reduction.
So you can see after seeing 600 patients, the rate of fat necrosis is a very high.
And so basically what we wanna do is try to avoid visible scars and have a very nice
volume distribution of in the breast preserve vascularity sensibility and of course you
have the less possibility of complications that we can have here we can see that the breast
mount is built basically with fat and the fibroglandular part.
So if we have the opportunity to reduce the fat that we have in this volumes,
we will have the possibility of have no scars and obviously at the same time we have a breast
reduction so as oncologic and plastic surgeons we know that uh anatomy is one of the
most important assets that we should know about it but at the same time what happened if we can
reduce the weight of the uh mammary gland in the tissue.
Are we able to get a lifting without a scar on it?
Well, let's see what happened.
So we want to maintain the shape, the function, and the beauty of the breast,
and we're gonna take a lot from the viscoelastic properties of the breast tissues
and if we can do this, then we will have no scars.
So let's say this is a patient that we wanna do a breast reduction with no visible scar.
And so here we can see the first thing is to design where are the areas that we
want to reduce the volume, how we're gonna do it in order to get a very nice volume
distribution but at the same time we still have in mind our proportions that the ideal
breast must have and obviously we have an asymmetry that you can easily see being one of
them. Of the breast bigger than the other one.
So what we do basically is we start with an ultrasonic lipo on both sides we already are
taking care of how much volume we're resecting from each part of the breast and.
When we, when we ended up with this, obviously, uh, after doing the,
the ultrasonic liposculpture, we wanna drain all this fat coming out and we're gonna
incentivate the skin retraction and we're gonna do this using the radio frequency basically
what we're doing is uh renewing that it's probably the higher radio frequency that we can
get. And what happened during the first month we're
gonna see that the patient hasn't reduced anything at all.
But then we see her 6 months later and what happened.
We have incentivated the breast reduction.
We have just followed up the patient with ultrasound and most of our patients go to the
next day to the hyperbaric chamber in order to increase the healing process in our patients
and as you can see as months are passing by.
The breast reduction is much more obvious, but we were seeing what happened with the with the
nipple areola complex.
Can we have the possibility of getting a breast lift at the same time of reducing the volume?
Yes, definitely. Why is this?
Because we're diminishing the amount of the heavy tissue that we have and then the nipple
areola complex are coming up and this is one of the great things about.
These patients because these patients have a better shape even in these patients that might
have a little bit of a tuberous breast, we can do the breast reduction of the volume we have
no visible scars and the patient certainly looks, uh,
happier once, uh, at least 6 to 8 months uh pass before we
have this kind of results.
So as you can see the patients obviously have a better symmetry because we already know what's
the difference between the right and the left side.
So when we do the process we can.
Be doing this here's another patient, and this is the same problem,
but look at the inframammary fault so we gotta do something in order to get a better shape for
this shape, uh for this breast.
So we mark our patients and then we start waiting month by month because you know that we
have, we're gonna wait at least.
One year before we have the end result, but using artificial intelligence we're able to
understand how much volume are we reducing in this breast and what happened at 6 months and
you can see that we have reduced on the right side minus 687 centimetres
and in the other side minus 800 and what happened when it happens 12 months after.
And here you can see that reduction is as time passes by reduction is coming being
less and if we go all the way to 2 to 18 months we've seen that the patient has really reduced
the amount of the breast tissue that we have inside.
But at the same time we have the possibility of having a better breast,
a better proportions, a nice volume contour, and obviously the nippa areola complex is gonna
be in a better position if you can see here what happened with the with the infram mammary
fault, we've been able to not only reduce the volume but the inframammary fault has raised in
this patients so I think.
Skin quality is one of the most important parts when selecting the patients for this kind of
results. uh, we gotta be that uh the breast volume and
distribution is gonna be what you wanna do you know which area you want to reduce more than
the other one and obviously how do we start this?
First of all, the patient's gotta be in the supine position.
We use treatments in the anaesthesia and intravenous sedation.
And we use the ultrasonic uh lipo sculpture and then we just drain all of this and then we
incentivate the retraction not just of the skin but also to the breast tissue with the radio
frequency. And here you can see we start normally in the
pre-pectoral area and once we have drained all this fat from the pre-pectoral area that we
know that that's probably one of the sites where we have much more fat in this area then
we start going in the subcutaneous space and then we finish doing the same.
Into the breast gland and when we do this, you know that we're gonna be able to drain really a
lot of fat from the from the mammary breast tissues and then we get to see the patient.
Why do we want to see the patient because if you see the patient that's the only way to know
if you're having symmetry if the volume that and the distribution that you plan ahead of
time it's gonna be. Uh, get it after surgery and if we do this,
obviously the possibility of having a scarless breast reduction is possible so.
And we continue saying to these patients what we can achieve is that the contour of the
breast is a lot better.
The nipple areola complex is better, and we're getting the ideal shape of the breast that we
want because you, you can work all the all the breast around in order to reduce the areas
that you really want to have more reduction.
And then you can see that when you take the heaviness out of the breast,
then the nipple areola complex and the whole breasts are uh uh in a much better position.
So here even in bigger cases like these ones you can see that uh when when we see the
patient we try to see.
Where do we want to have the end point of this because we need a lot of retraction in these
cases in order to get this liber Ala complex to come up?
Are we gonna be able to gain all this uh space in order for retraction?
Well, basically.
We will incentivate skin retraction using the radio frequency at the end of the procedure.
And when we uh end the procedure we gotta see what happened and basically we
have reduced the heaviness of the breast tissue. The breast is in a better position we have just
one scar and when you use uh the radio frequency you need another port in order to get
the gas out of it, you know that in order to get the plasma you need the the the
gas as well as the radio frequency.
But really I think that uh just trying to get the follow up of all of our patients
is the only way that we can do it. We've been doing this for 10 years.
The publication is coming now and uh I really want to say thank you for all of you.
And my OR is always open for anyone that wants to come and visit us,
then please feel free in Mexico we have one saying and it's mi casa est to casa,
which means my house is your house.
Thank you very much.
Thank you so much, Abel, and I would like to ask uh Mark Cheveran to talk about transTXA
actually friend or foe?
Uh thank you, um.
This is my disclosure for this talk is I'm not an expert on TXA,
so I apologise in advance, but I do use it, and this has been a real opportunity for me to
evaluate my practise and really see what is there in the literature.
Obviously there are some experts in the use of TXA that hopefully will be able to share some
of their experience.
So my interest started with with this case. So um uh this was a,
a patient uh with a recurrence, elected for um bilateral er skin sparing mastectomy,
she had lymphedema.
She's obese. And we noticed after the skin spraying
mastectomies and as the flap was being raised, things were bleeding a lot and um the concern
there was this is a patient that's going to require transfusion.
And so what, what could we do? Was it safe to use TXA in,
in a case like this, we're gonna be doing microsurgery.
And around this time, you know, TXA was really being exclusively used in those multi-panel
cases, uh, the really big orthopaedic cases, um, even around,
uh, microsurgical reconstruction, but those tended to be our buried fibular flaps whereby
they're not necessarily being monitored and and that you know that the data was kind of
accumulating in this space, so.
If I was to use TXA uh in this case, uh, firstly, would I use it,
uh, what dose would I use and, and how would I use it?
So. From looking through the literature,
specifically what I wanted to look at was its use of mastectomy and its use in microsurgery
breast reconstruction.
So firstly, what is TXA? Well, it's antifibrolinic.
It reversibly inhibits the activation of plasminogen to plasmin and therefore prevents
the breakdown of the fibrine clot.
Importantly, on the contraindications of the use of combined hormonal contraceptives and
either active or a history of uh thromboembolic disease or those who are at high risk of it.
So what studies have been done? What are the,
the real important contributions to the literature?
So firstly, let's look at this broadly.
So, um, this was a study from Annals of Surgery in 2021,
a single pre-op dose of, um, IV tra aic acid and meta-analysis.
Um, and so it included 57 studies, um, and, and, uh, from a variety of surgical specialties,
and it demonstrates the 72% reduced odds of transfusion.
Um, in surgical patients that receive this pre-op.
Um, however, no difference to the instance of, uh, venous thromboembolism,
uh, between, uh, treatment and control groups.
Well, how about plastic surgery?
So there have been a few publications recently in PRS which we'll go through.
So this was in this was published in last year, clinical applications in plastic surgery.
So a systematic review and meta-analysis of 45 studies.
Um, I'll break those down in just a moment, but what they concluded was that further high-level
studies were needed to determine the effects of TXA on hematoma rates in all breast procedures
and also in in microsurgery.
But what they noted was that that no article attributed complications that included VT
events to the use of TXA or demonstrated higher complication rate in the TXA group,
specifically for reconstruction in breast procedures, there were two articles that looked
at this both on implant-based breast reconstruction, one where IV was the route of
administration, demonstrating a significantly reduced hematoma rate,
and the other applying it topically, demonstrating a reduced seroma rate.
But no difference in hematoma rate, which will be a theme that we'll see.
Uh, regarding, uh, uh, microsurgical reconstruction, two studies,
both retrospective cohort studies, both IV dosing.
Uh, the first by Valerio and colleagues, uh, demonstrating no significant difference in flat
failure rate. Both studies demonstrated this,
um, and the second study by Lardy and colleagues, uh,
demonstrated significantly reduced intraoperative, uh,
blood loss and hematoma rate.
And again, no difference in flat thrombosis.
Another um systematic review this time in the annals of plastic surgery in 2023.
Evaluated the use of TXA in all breast surgery, predominantly mastectomy made
up 14 over 1400 cases, 13 studies included.
It demonstrated 75% decrease in odds of hematoma formation with any route of TXA
compared with controls for oncological mastectomy.
And a 56% decrease in non-oncological breast surgery, uh,
which was also significant. And again, no adverse effects,
including VT, PT, or increased uh hospital stay.
Again, in PRS in 2023, systematic review meta-analysis of TXA's use in breast
surgery. So this time 5 studies met the criteria.
Over 111 patients, this time undergoing mastectomy with or without reconstruction and
also breast conserving surgery, and they found that IV use of TXA significantly reduced the
risk of hematoma. In the treatment group and a seroma formation
was also significantly reduced with no increase in thromboembolic rate and a decreased rate of
surgical site infections in the TXA group again, which has been a historical concern of TXA and
here are the um the forest plots demonstration that all studies are showing an improvement in
hematoma formation and seroma formation.
This is a really elegant study from our colleagues in McGill,
uh, in PRS in 2023, an inpatient double blind randomised control trial of the use of topical
TXA after nipple spraying mastectomy. So the patients with their own controls,
one breast treated, uh, one breast was the control.
And whilst they didn't find a reduction in hematoma rate,
they found a reduction in drain output, and they found that drains were removed faster.
They also found that THA group actually had significantly fewer complications.
And here are the graphs clearly showing that compared to control,
there was a significant improvement, reduction in drain removal and also a reduction in drain
output. This is another randomised control trial,
uh, answering a similar question, again, mastectomy, uh,
wounds, uh, topical tranexamic acid, uh, double blind RCT again,
uh, uh 200 patients, 100 in each group.
Um, TXA significantly reduced drain output, reduced hematoma rate,
um, no postoperative difference in postoperative complications,
um, and there was no difference in late hematoma aspirations.
A trend towards decreased hematoma rates didn't meet clinical significance.
Physical certificates, I beg your pardon.
So, um, how about, um, IV TXA in implant based reconstruction.
So this is a, a single centre, uh, retrospective study.
TXA this time given before the incision and then at the end of the case,
given IV. And they found that the TXA group, as we are
seeing a theme, developed less hematomas when the administration is by IV compared with those
that did not, no increase in adverse events and identified some useful
risk factors for hematoma risk or moderate analysis, age and hypertension,
which have been shown in other studies.
And here, difficult reduction hematoma risk.
And then this is a study from Uh, um, Mr. Fra and,
and, and colleagues, uh, from Switzerland, uh, looking at the use of TXA in microsurgery,
retrospective single cohort study.
Almost 100 free tissue transfers for breast reconstruction.
Patients with a history of ETA were excluded.
63 free flaps received TXA, and the patients received it intraoperatively,
and then it continued up to 24 hours postoperatively, up to 3 grammes,
depending on, on the blood loss. No thrombosis of the microsurgical anastomosis
and um.
The blood loss, intraoperative blood loss was significantly lower and postoperative with the
administration of TXA and here are the pertinent information.
And so this is what the study er er stated and um I think this is important to to bear in mind.
So um TXA must not be used in prophylactic manner, uh,
considering that blood loss can be managed uh with hemostasis without TXA treatment.
And this is interesting because um to apply this uh data to this case,
uh yes, the patient should receive TXA they should receive it IV and uh starting off with 1
gramme and then redosing it as necessary.
But I think we still have many questions left unanswered, so you know,
is TXA a friend or a fellow? I think we can say that it's a friend.
But I think we do need more evidence, um, particularly the preoperative use in
microsurgery by it does stand to benefit us most because the perforated dissection is
considerably complicated by intraoperative bleeding, and then also to determine
the appropriate dosing, the safe dosing.
So definitely an opportunity for further multi-center prospective studies.
Thank you. Thank you, Mark.
I would like to uh now open the floor for any questions or comments.
Yeah, Mo.
This, uh, is a question for Mark.
um I just wanted to kind of share a case uh with you uh it was a patient I had done a deep
lap on everything went well.
She was in the on the ward, started getting swelling of the breast,
took her back to the operating room. She had a hematoma.
We evacuated the hematoma signals were fine, you know,
arterial and venous flap was bleeding great.
The guy I was operating with said, let's give TXA, and I said,
all right, fine, I've never used it.
So we gave it IV I think it was 3 grammes.
Sure enough, you know, I think whatever was oozing slowed down,
but what was interesting was the oozing on the surface of the deepithelialized flap also
started oozing, and there was a significant reduction in our Doppler signal.
And I thought to myself, you know, what is going on here physiologically,
you know, I know there's the, the benefit of, you know,
the, the bleeding to stop, but what's it doing to the vasculature?
Maybe it was a fresh anastomosis that it had an effect on lasted for about 15-20 minutes and I
was like starting to panic thinking, oh my God, now we created.
Thrombosis and now we're gonna lose this flap, but then it wore off and and we gained regained
a strong signal. I mean, any explanation on what it's doing to
the vasculature when given intravenously? Well, that's always been the consensus you gave
3 grammes, that's that's a hefty dose uh so um is the first thing I would say,
um, obviously the pathways are different in terms of its mechanism of action.
The only thought there is.
What was underlying the hematoma was there already some beginning of a flat compromise and
fibrine deposition at the anastomosis that may have been.
You know, propagated by by that process, but um, no, the mechanisms are different and that is
always the concern of using it in microsurgery is anything that's prothrombotic seems like a
bad idea, but the mechanisms are different. I just,
yeah, I, I, I've, I've not experienced that and again I went into this with a lot of
trepidation, using it in microsurgery, and I think we do need more evidence,
but my only thought was I don't know whether there is some systemic effect of giving such a
big dose. Yeah.
Cause it, it's dosed by kilogramme of body weight.
Just taking on that, um, I know the literature is very conflicting about the dose.
You can give 1 gramme pre-op IV. You can give topical,
you can give 1 gramme and read those every 8 hours.
Did you find anything that you think it makes more sense when you were?
Well, yeah, so I mean, that was my one of my questions was,
well, how long should I give it for? And you know,
obviously oral is also an option.
And does that come into this this at all?
It appears that it doesn't.
It appears that topical doesn't reduce the rate of hematomas,
but um. The, I, there is not good evidence for giving
it for longer than 24 hours after the surgery.
The question though is at what point do you decide to give it.
And I think this is the type of situation that I'm beginning to think about.
This is an obese patient, bilateral he, bilateral skin spray mastectomies.
They are potentially at risk of needing a postoperative transfusion,
which is really a no no this day, this day and age.
And so I think there is a role for giving it upfront even before the incision.
In, in, in those patients that are meeting those sorts of risk factors,
particularly the surgery is going to be prolonged, and you know,
because each hour that the patient is open, there's more intraoperative blood loss and a
higher risk of needing transfusion. So I think that's where I'm not entirely clear.
I really would be interested to see who's got experience, you know,
with using it preemptively because it does as soon as you give it,
then the operation becomes much. Easier, you can now see your perforators,
you can do your dissection, and so it does make you wonder if giving it up front would be a
logical thing to do. I haven't got to that stage it preemptively yet.
I do. I'm reactionary, but I think that's perhaps the
next frontier in this.
Just a quick question for the audience who gives TXA to their patients before surgery for
any breast surgery? Wow. Yeah.
Yeah, it's usually a Grand Pri-op, I would think that's kind of a.
Yeah. Do we have the microphone at the back?
Mhm Cases or um implant reconstruction.
We did an audit, uh, obviously we became more, um, worried about the
6%, and we knew hematoma is not good for us, so we took more care
and when the paper published in 2021 we started giving 1 gramme
of um um transezemic acid before the surgery during the induction.
Um, for all sorts of breast surgery, uh, that percent came down to almost less than
2%.
And now if the procedure takes more than 3 hours, we will add another 1 gramme of,
uh, uh, transzemic acid, and we don't give it any more after that.
Perfect. Very, very good thank you.
Um, I have a question for you.
I loved your presentation. I've, I've seen you presenting before,
uh, but I think it's really important to be on cutting edge.
I think this is the future, as, uh, JP talked about yesterday,
robotic surgery, it's in a tipping point right now, and now we're,
we're gonna see more acceptance, more people, um, you know,
get involved in robotic surgery.
So I think it's really important to do the technique and to prove that it's very safe.
We have a trial going on in US as, as, as you know, um,
so far the data has been extremely good.
We don't know, I don't know for how much longer they're gonna follow.
But if you look at robotic mastectomy endoscopic mastectomy,
I would think in terms of data of safety has to be very similar and
endoscopic mastectomy has been here for a long time, so I would love for you to comment on the
data, um, on the safety because I think it's important.
I really want to see more people doing this procedure because I think it's best for the
patient. Thank you for the question.
For sure, endoscopic surgery was done by Japanese surgeons since 20 years,
so now we have a lot of data, a lot of follow up, especially about breast cancer.
This is the data we don't have for robotic surgery because we started in 2015,
so we have 9 years of follow-up for breast recurrence cancer,
but we need more data and We have 2 options. We wait and see the data or we make the data
by ourselves. So for sure it's always better to include
patients in a clinical study, but today for endoscopic, there is no discussion.
We have all the data we need for robotics we have, we have to make the story.
Do you think I feel like the single port will be the
device to do these robotic mastectomies. First of all,
the company needs education, which is great.
Um, second, it's because you do reduce your incision to one port only,
and how do you feel your experience between the single port and the and the and the XI.
So I have to say I have no experience with a single port yet because it's not available in
my hospital, but for sure if you can reduce the scar, it's always much better and It was very
difficult to do um single port surgery with the XI, so the previous version of the robot
because the arm was not made for that.
But with the single port I'll show you on the video, everything is,
is well done to, to do it easily. So for sure,
uh, single port is the next step.
Yeah, I do hope that in the future we can do what JJ Huang is doing already in in Taiwan,
which is the robotic mastectomy, robotic JP free flap,
and robotic reinnervation of the breast, which is like probably what we should strive for.
Yes, on the back.
Can we have the microphone please? cavity.
What sort of millimetre mercury pressure you use when you do laparoscopic or
robotic uh mastectomy.
So when I, when I put a gas inside the breast, it's between 8 to 10.
It, it, it works very well and it's enough because we just have to lift the weight of the,
of the skin. So it's quite easy.
For sure, if you walk um under 55 millimetres it is not enough,
but between 8 to 10, it's enough.
You got a question? I've just got a question for Abel.
In terms of your ultrasonic liposuction, is there a particular plane that you do it in,
or is it throughout the whole breast that you find that it helps to get your skin to contract
afterwards? Oh thank you Merlin.
Yeah, the first thing that I do is once I finished it to mass and infiltration that I do,
I start in the supra pectoral space.
This space specifically when we do the breast talk, you can see that we have much more fat
than in between the glands. So the first part that I do is the supra
pectoral muscle, uh, fat resection.
Then I go to the lateral parts where usually we have much more volume we go in the subcutaneous
space and then I start doing all the holes in the gland so uh one of the lectures
that you asked me to give was how to deal with fibroglandular tissues and.
When we realise that every gland has a part of fibroglandular tissue and a part of fat,
so we're not dealing and we're up to now after 10 years we do not have any problem with the
fibroglandular tissue.
We just make a lot of holes inside the fibroglandular tissue and we're able to get all
the fat out of this and I think this is the way that we can really get the contraction because
we need the contraction not just on the skin.
But also in the tissues in order to make the inframammary fold to raise and also
to flip the nipple areola complex in position.
I got, I got a I got a quick question. I mean,
I don't do breasts, so this may sound very ignorant.
What happens to the lactation function after liposuction?
What happened to the to the functionality of the breast lactation uh they say that
breastfeeding, uh, the breastfeeding well, fortunately this patient has had the
opportunity to breastfeeding with no, no problem.
We're, we're not really separating the, the gland from the ducts.
So we still have the function of the gland.
Probably if you wanna have a breastfeeding immediately it's not gonna be possible but once
the swelling is down they're they're able to do it not possible after robotic mastectomy,
no breastfeeding. I do have a question about beautiful cases and
the same, the same, uh, thing as Marlene asked.
Do you have, so use Renovi to tighten the skin.
So you go immediately into the subcutaneous plane and how do you make sure that you get
an even contraction of that skin envelope? What's the learning curve to do that because it,
it looks very, very, very good.
I, I start doing the the radio frequency, the renion.
But you know the first thing is that you need another small incision because you cannot just
get the helium, get inside and no no way out, so we don't wanna have a pneumothorax or
anything else, so you need another port, very small one,
and once you start doing it, I try not to do it just.
On the subcutaneous space I tried to go also into uh if you see how the rate of frequency
works, it starts giving the energy all around the port and all around the
device so once it starts stretching everything, the first thing that I noticed on my first
case is that I have a nipple retraction.
And so I told the patients, you know, we're gonna wait until you,
the swelling comes down, and then if I need it, I will cut the dogs that are shortened.
The thing is that it behaved by itself.
I never had to do anything else. Now I tell the patients I'm gonna do this and
probably your nipple is gonna come like a umbilicated nipple,
but then it comes out and pops out perfectly.
So you have to do it all around.
All right, I think Gion's giving me the signal.
You want some coffee?
I think the next session is starting at, uh, what is it?
3, 3:45.
All right, thank you all the panellists.
Thank you.