Welcome to the afternoon sessions, and everyone knows my uh co-chair Konn,
who's one of the most brilliant microsurgeons I've known.
And, uh, I'm going to introduce our first speaker, Raymon,
who already gave a talk on lapofillin, but he also kindly going to give a tribute to one of
the uh lost plastic surgeon who recently passed away very kind of him.
So. Um, at the request of the scientific committee,
uh, and, uh, uh, their sensitivity, we, we wanted to,
uh, render some, uh, tribute to Eric Eau Claire.
um, he was a former presenter, uh, in, in this, uh, very meeting,
and, um. Uh, passed away uh last November.
Uh, Eric, uh, I got to meet Eric out of, uh, two
instances. One is a member of Europe's and I just kept
with him over the last year, um, some exchange in trying to get some French delegates to the
Europe's meeting in Mallorca next May, but the other, uh,
more kind of a long standing, uh, common interest is fight grafting,
and that's the reason, uh, and the topic of my my next talk.
Uh, Eric actually was a brilliant mind, uh, wanted to be an
architect, and, um, uh, when he was 17 years old, uh,
his father, a doctor himself, passed away and the family pressure as long as the
peer pressure of other of his friends who joined medical school.
You know, uh, put him into medical school, um, was graduated at the,
uh, Paris, uh, medical school and, uh, uh, trained under Daniel Marsha.
Uh, he soon, uh, became, uh, an outstanding and, uh, quite a
contributor in, uh, uh, face lifting techniques.
Until 2013 when uh with uh Dan Delvecchio and uh Phil
Blonde published uh what we consider uh uh a landmark uh article
on composite breast um mementation from that on uh he elaborated his technique
and he was able to master that.
He was president of the French Society of Aesthetic Plastic Surgery and a long term
member of Europe's among other things.
So for those uh who just kept with his, uh, literature search,
uh, his literature contribution and and and those of us,
uh, who basically enjoyed his, uh.
Um, his teachings and learnings, um, uh, a, a thought, uh,
is, uh, requested out of you from the scientific committee,
uh, the, the scientific committee of London res meeting.
Thank you for your sensitivity.
In a moment that you're gonna do the first uh uh lecture also you bring some clarity in the
whole life fulfilling, uh, thing and you're gonna compare the different techniques.
Thank you. uh, just before we started the this uh meeting,
um, uh, Kuon in his, uh, usual kind of a cynical approach to things says,
well, nobody's talking about, you know, the important thing which is what we
inject. OK, well then I'm going to try to answer that
question, you know, uh, especially in comparing these techniques and with the thought
or a hypothesis, the more the cells, the better.
Uh, a disclosure, um, a co-inventor of the Revolve, uh,
uh, and also a founder, a founder and a stockholder of GID Bio both devices are going
to be, uh, um, mentioned in this ongoing, uh, presentation and a
disclaimer. The volume retention rates that you're gonna
see, uh, are for orientation purposes, uh, only, um, they would not,
uh, withstand a meta-analysis.
Here it is um um a view of a subcutaneous adipose
tissue. The speckles that you see in here are no less
than about 100 to 120 micron uh mature adipocytes, and the fibres that
you see there in white are what we call the stromavascular fraction that holds into
these fibrous net lattice that brings this adipose tissue together.
The question is to answer Kuhn's question, what are we injecting?
How many cells are in 1 CC of fat, you know, just for comparison purposes,
I'll tell you, I'll remind you that in 1 cc of blood there is about 5 million cells per CC.
How many cells do you think there is in one CC of adipose tissue?
Well, it is 11 million cells.
Uh, we published this, um, about 4 years ago, and this is going to be
the. Uh, the argument that is going to
basically follow and compare the different techniques that we're gonna see next,
so the cells are related with the graph volumetric retention and in order with
that thought on we're going to see different techniques standardising the graph,
selecting the graphs or augmenting the graphs with cells.
Um, you will all agree that lipoaspirs, which is the source of our fact graphs,
it is a variable.
Um, these are three different examples, and you can see the different water composition,
water. Action out of this lipo as it is then logical
then that if we inject everything but the sink out of a lipo aspirate sample we are going
to get variable rates of resource that is evident to us all.
Another question is the particle size.
The particle size has been long debated and um let me kind of solve
this once and for all since the data that I'm going to give you is not going to be,
uh, it was not only mathematically assumed or predicted but also confirmed in vitro and also
in vivo. So basically when we try to establish uh uh
uh relationship between the burning rate of oxygen and the fusion rate of oxygen
and now we know how many cells do burn oxygen 11 million cells per
CC. Then we can establish this curve between the
cell concentration and the graph radius and if you establish this constitutive cell
burden basically the cell concentration that populates a fat graph you will realise that the
graph radius of approximately 1 millimetre is the threshold by which beyond that
the core of the particle would be rendered hypoxic and therefore.
Uh, uh, necrotic unless this, uh, bio burden is organised
in kind of a vascular particles that are easily inosculated and,
uh, sorry, and, uh, finally.
Um, revascularized in such a way that the whole thing is not based on diffusion
but is being perfused.
This should happen any time before 7 days.
Uh 7 days is the amount that the adipocyte is the time in which the adipocy remain,
uh, viable without, uh, uh, properly perfusion, so.
With this if we are able to maintain standardise the physical composition
oil out water out and.
We are able to standardise this fat grafting, you know,
we will all agree that reports uh go around a 50% of retention
rate, uh, long term.
However, we wanted to go beyond that if not 50%, at least they are
reproducible that's why the take home message of this stock is please know your graph.
Use your graph in a consistent manner so at least irrespective of the retention rate
your results are going to be reproducible.
So with this at hand we look at previous reports that basically establish that fat
graph constitutive fraction stromavascular fraction, um,
uh, is a predictor of, you know, the graphs volume retention when you take all these
different. Uh, recipients and then you plot the amount of
these cells with the volume retention they uh they achieve you can see that there is a
correlation between the amount of cells and the volume retention.
That's why we came up with uh revolve, a device that basically takes these
particles, one's rich in cells, the other one, you know,
um. Decellularized and then when they are uh
catched by the philtre, the ones with less cells therefore the ones more buoyant than are
discarded while retaining the high cell density fire graphs.
When we did that in vitro we were able to see that the um volume
was larger, the oil contents was much less, and then the amount of
cells in the fat particles retain.
infiltration are much higher compared to the cells to the particles that were
discarded by any filtration device, the revolve or any other devices that are
currently in the market today.
Um, more than that, I'm proud to kind of, uh, show you this picture that I
took myself in which you can see, you know, the vascular and lymphatic vessels that are
preserved in small particles once they have been washed,
rinsed, and filtered.
So that's why we propose that one way to standardise your fire graphs would be precisely
one of these many.
Devices that you have that do exactly that when you do this,
then you're able to bump up a read a little bit your your retention rate to 60%.
OK, now then the question comes, well, if, if then volume retention is a variable
to cell density, let's increase the cell density in such a way that we can increase the
volume retention in our fat graphs.
One way to do this is uh. You know, sacrifice one part,
one volume of the lipo aspirate, digest it, obtain the cells,
and then add these cells so enzymatically dissociated to the fact graph that we're going
to implant.
Now this is basically um.
A study that we performed in Spain under uh uh European Medical uh
agency approval by which we did precisely this so we took let's say
200 ccs of fat and we standardised that by filtering, washing,
combing, and straining.
And then another 200 ccs were done just like this but digested centrifuge and
resuspended in, you know, this stromovascular fraction in an isolated form.
I want to stress that that it was isolated because we're gonna see other aggregated forms
to enhance our fat graphs with this we when we did that.
In vitro we were able to see that the fat graph was indeed revascularized properly,
you know, and not only that, you know, we were able to see how the exogenous cells that we
added when they were attacked with red fluorescence protein were able to basically
incorporate themselves into the vessels of our fat grafts.
So you know the in vitro and histological data supported this study that we published in
2005 by which we were able to see that there is at, you know,
about 18 months of follow up, you know, about, you know,
7%, 70% of postoperative volume retention index.
Another interesting finding that I wanna share with you is that there was not only statistical
significance in the long term follow up as far as volume retention but also that there was a
lower inflammatory reaction in the early stages post implantation of the fat graft.
Now about 7 years later, uh, our colleague Fred Coley in Amsterdam,
Copenhagen decided to just take this fresh thing and then went ahead and um.
And then uh uh expanded the storm of vascular fraction and with that we're able to bump it
up at 70%, you know, now how about the mechanical disaggregation,
the mechanical disaggregation was, uh, obtained by sheer force,
you know, removing the uh uh mature adipocytes and therefore using these stromal aggregates to
enhance the fact grafting.
In this way we are able to obtain, you know, a very high concentration of
cells in the stromavascular fractions.
Um, um, as you can see, for instance, uh, in this look at the plethora of cells that
are obtained when we, uh, merged these or mixed these stromal aggregates with
fat grafting, we were able to see a bump in the uh volumetric retention,
uh, you know, post uh post implantation, so we were able with graph volume
retention. 75% of these fresh stromavascular aggregated
cells. Now I have to say that when we do this,
you know, you incur in a very steep expense, not only sacrificing fat graph volume
but also for instance if you want to obtain the amount of cells that.
You do by expansion then you are going to uh face a bill that approximately
uh that approaches €25,000 so if you wanna do a breast augmentation,
you know, and charge only for um um uh uh sales um of
25,000 be my guest.
So in conclusion what I would recommend you to do is please standardise
the physical composition of your fat graph select the fat graph in such a way that your
size and cell contents are maximised and reach if you can or possibly do
and above all know your graph.
Thank you so much for your kind attention.
I think they're gonna come a lot of questions, but we're going to keep them for the for the
end, so. Yeah, the, uh, the next presenter is Roy who's
gonna talk to us about pro preservations with.
Thank you so much. I just will talk about, uh,
a new method. And uh The As,
as always, my disclosure, I'm a temporary consultant from Li Bank.
I will talk about Li Bank.
That the lapa filling is in the luggage of all of us.
Uh, we use more or less in uh in our daily practise and
actually. With what is our final goal using lapofilling
to increase the intake to decreasing the session number is quite easy because we
actually know that there is an Achilles heel that is the number of sessions
when we use the uh lapo filling in breast reconstruction, uh,
sometimes we need to do 2 to 3 sessions. It means that for the patient it is 2 to 3
surgery. Uh, also, if we do in our patients,
also if we do under local anaesthesia and sedation anyway,
is a surgical position. The patient will do,
will say, I had a surgery.
Well, the possibility at the moment is not do in uh
in just in one shot, but uh we would like to to transform actually
the surgical procedure in a filler session and the, the.
The dream came true thanks to this Italian company that was able to
do a clear preservation of our fat. Then we do in one session we collect the most
that we can. We divide it in small bags of 120,
130 and and then we asked to to defreeze the fat.
Uh, we need 48 hours before because, uh, this company is connected with the National
centre for Transplant because they have a lot of certification and,
uh, uh, we don't have it in Rome and we, we need to call from,
from, uh, one of the, the centre, the transplant centre that we have in Italy is
close to Bologna and, uh, um, they bring us the uh the fat and.
When we start with the uh with a very uh thinny patient in which we know that she will
undergo through a a lapo filling we collect the fat in the same surgical procedure when
we do uh the cancer removal and the uh reconstruction, we take the fat and then
it becomes just a filler session, the, the uh um when we transfer the fat.
Go and see a short video, uh, that's the, the patient in pre-op,
um, the implant was very visible.
uh, the patient was quite generous about adipose tissue.
Then we had the possibility to collect a lot of, of it,
and, uh, we did the first session uh in, in the same at the same time and then,
uh, the, the other one in, uh, along the month.
Uh, not before then 2, between one and the other one.
we go and marking all the area, then we want to treat, and,
um, then we go to the OR to do what you do every time,
the client solution before, then we take the fat and,
uh, and we collect the fat in, uh, in small bags as I,
as I said to you before and uh.
It's the um we we we give the, the, the fat to this the the bags.
We do the decantation, we remove the water and We
transfer everything in one single um huge syringe of 60 cc.
And then we put in the, in the bags.
At the end, uh, we, we give the bag outside. They will put the,
the label with all the patient details and uh it's collected and then
we actually in a case like this one we have 910 bags that we are able to
insert. That's the what will be attached the label we
put inside and we send to the.
Uh, to the fat bank, the LIBO bank, that's it.
Then we wait for some months and the back is back.
And we go and we transfer everything in a huge syringe and then From that we try to don't
lose anything. We moved to a 5 cc syringe for the injection.
We try to use a small pressure on the on.
Then no, no more than 5 is 1 millimetre or 5. It depends how,
how much fat we have to transplant. That's the,
uh, she's another lady actually, just because I, uh, I did the video and I talked to the patient
about, uh, I did a mistake because I am everything.
I am the art director, the screenplayer, the editor.
I do everything when I do my video and, uh, she was totally covered and then.
Uh, you, you could hear me but not not see the injection.
Then usually what we do is what every one of you does generally
small tunnel close one to the other one but not connected, uh,
just to have the possibility to have the major intake that we can and different,
um, tunnels and sorry I need the, the, the audio.
He you know
Kenya And that's No.
Contest. Uh Brute
Just to tell you that we do under local anaesthesia, the patient is awake,
uh, it's exactly afi procedure, very, very easy, and the problem is the
reimbursement, but if you want, I will answer all these questions.
And then uh when we finish up, we will, we will say the uh the final results
and uh, oh, just a little, a little trick the um.
We put the stitch with the cannula with the micro cannula in because the fluid is very
fluid the fat and then just don't lose any single drop of what we put it in.
And then the pray and after 5 sessions, the patients and pre and post op.
That's just some other small cases just to say that we can go and and and make also some small
refinements like I don't know, uh this one in the inframammary fold and the um
ultrasounds that can show us before and after uh the increasing of the um the the
tissue thickness.
Then I think that Lipo bank actually, uh, at least in Italy,
um, could. It is a great opportunity for us and uh we are
we are doing all the studies to to understand uh many things about about the intake
but anyway the procedure now really became something so easy to do and the patient doesn't
not consider anymore to have additional surgery because they they are doing.
After a session like this one, she actually dress and goes home without any problem because
we use probably less than one vial of local anaesthesia because you know that after a um a
reconstruction, the feeling and the sensitivity on the skin is,
is really poor and then you don't need to, to, to give so much we don't use IV anaesthesia at
all. It's really a local position then thanks a lot.
Thank you very much for your attention.
So, the next speaker will be uh Klaus Uberreiter with total breast reconstruction
with autologist fat grafting. Close.
So thanks again. I'm not spoiled for anything here.
The breast reconstruction we have heard now filling deficiencies,
rippling we have seen in the morning session and everything.
We also do complete reconstructions.
The big advantage is you have a sensible breast. You have no different colour of
some deep flab or other.
It's a feeling it's not soft.
The disadvantage is you have to do it in several steps.
And I, I understood, yes, right now you took 5 steps for your frozen fat.
Uh, and you can repeat the procedures every 3 months, so a
complete build up can take a lot of time.
Then Kronowitz study and the Galle study from Manchester and
it's quite safe and the starting point will be when the patient
is ready for some ordinary reconstruction with
implants or deep flaps or anything.
And of course, there must be enough fat.
You can earn fat, you can over eliminate yourself that you have more
fat, but if you lose it afterwards, again, you lose the breast volume.
So I designed this as Ramon said, very important.
Uh, 2010.
And here's a short video about it.
Basic infiltration, not much with the water assisted.
Liposuction device and I have a double loom cannula, and the inner openings is only
0.85%, so we harvest the fat with below 1 millimetre.
Right, Ramon also said it's good. This is lipo collector.
In the beginning, I took it under the microscope that's from a normal saline
assisted liposuction.
This is after centrifugation. It's more a little bit like pudding.
And this is a water harvested fat, which looks almost like the understaled fat we
have just seen.
In a month there's a philtre in the bottom which take out
the oily debris and everything, and then I take it with some large cannulas.
I usually take only one incision.
From the side and fill the breast.
And you see this very, very small intact fat lamps.
At the end, the patient gets some cotton.
To keep it warm.
If you don't do anything, they don't feel comfortable.
Easy cases from the beginning, not irradiated, no implants,
no nothing. And I had the luck I could start with such a
patient to get some confidence in the method for grafts,
and then it says failed free flaps, which usually don't occur but only rarely
you can fill up with fat again.
More challenging is if the patient had some radiotherapy.
I tell them they need about 4 grafts only to cure the radio
damage, and this is a small volume.
They cannot expect to get a big volume in the first hand if you try to inject a lot in a
radiated breast, you will fail.
Then it is above for volume, and it can be up to 10 procedures
in total. The good thing is it's an outpatient procedure.
It is very fast.
For instance, if I have an operation where need only.
5100 millimetre that doesn't take me half 10 minutes, 15 minutes.
And here you see the, the series of the patient, but at the end she's got
a sensitive, normal appearing breast.
And that makes very telling.
She's very happy with it.
If you have more, bigger breasts, then.
You enhance.
We have had this all the time.
Today we must enhance the layer, the tissue coverage, otherwise you have
no chance.
And I would recommend an expander with a separate valve under ribs because if
you have a built-in valve, it's like a champagne cork,
and if you remove it afterwards, you have a hole, the central hole,
which is difficult to cure.
And this I can deflate until it's empty and take it out of a small incision.
To get enough skin in certain cases, I had
the idea to leave a patch of fascia attached to the skin.
The problem is if you do an abdominal advancement and pull the skin up,
you take some abdominal sutures.
Sometimes it works, but usually it tends to get down again.
Therefore, I take a good stripe of the abdominal fascia,
leave it attached, and I have a very strong anchorage.
I will show you.
Usually you can up to 5 centimetres, you can lift the skin.
That will be the future sub memory fold.
And then I design.
The area for the fascial patch.
Use some pre-existing scar wherever they may be, for the video,
of course I was lucky.
Took some down. You cut under the fascia.
mobilise wide.
And former Pocket For the pets Which
you can fixate with a double row of y.
And then put the expander.
Close the skin, fill the expander.
That's not for me.
Storm up and there says.
Some examples if you want to.
Must that noise be? OK.
And it's uh pulled upwards and it's a very stable sort of fixation.
Am I still to hear?
And uh Another example, a patient who had a an
implant with capsular conjecture, and I removed implant and all
serious and.
This at the end is only fat and no implant, for I don't use implants.
I am the lipo filling guy.
And that's why they come.
Again, example, removal of implants.
Some Better tissue coverage before and then reduction,
right, and then you have it.
Capsule conjecture is different.
I treat a lot of patients who have implants and capsule contracture and usually it's quite easy.
You take out the implant, you grab some fat round, and then it's OK.
And But in this case you never should do it
in one step.
I didn't know. And when I removed this patient with an
expander, she had a negative impact of the breast, indented ribs,
and it was quite terrible afterwards.
It took me a long time, but finally I could achieve.
Resolve, but it could have been done a bit more elegant.
Again, a patient with capsar contracture, right?
filling and that's she at the end.
I offer my patient, for I cannot harvest the fat very exactly.
Sometimes there are some 1020, 50 millilitres left over,
and I asked whether they want to put it in the other breast,
and she wanted it.
So One of the most challenging Situations
is if you had radiotherapy, failed flaps, anything like this
patient who had MRR infection afterwards was 3 months
treated in the hospital with vacuum.
I had a salvage flap.
And uh she was really hard to persuade to do anything at all.
So we In fat, a little softer every time I got
excise some of those scars, and she wanted the areola removed,
for she was very nervous about getting some cancer again,
so she wanted it completely, and that's the final result after many steps,
and this picture she sent me only two days ago said I have a new life.
She was really a mental cripple when she came, you may imagine.
The satisfaction rate with this method is very high.
Some might tend to say, well, if we need such a long series of fat
graphs, it can take up to 2 years or even 2.5 years, but.
The satisfaction is high for the patient. I don't persuade anybody against deep flab or
anything. They come to me because they search for an
alternative for implants or deep flabs.
We had, we published it with uh Helsing and.
In Finland is very popular.
So I think fatcraft is a really great tool. You can do complete reconstruction.
You must be modest, you must take your time.
Don't try to achieve it in a very short time.
And you can read more if you want.
And yeah, that's my clinic capsule before. Thank you.
And now we have a last speaker at Chang.
At oh sorry.
Who's gonna talk to us about I was uh I was distracted by the uh the talent in the corner
over here. um, first and foremost, uh, it's an honour to
be here and to be included in this, uh, wonderful congress with a really a bunch of uh
masters in the field of breast reconstruction. So thank you,
Doctor Farha, Doctor C.
Uh, Doctor Masilia for including me, um, so this is an interesting topic.
Uh, I gotta be honest with you, it's not really my expertise.
Um, I do have, uh, some consulting with, uh, MTF, but,
uh, the management of, uh, oil cysts and fat, uh, necrosis,
you know, I could tell you that I don't really have a good experience on this because it never
happens to me, but that would be a lie, right? Like anybody that does liophilic know.
Fences you must have encountered at least some degree of complications with uh with uh fat
necrosis and a lot of it maybe didn't come out in their talks though but it's some of the
subtle techniques that they're talking about that could potentially minimise this problem
essentially you know the gist of it is if you have an oil cyst or you have a significant.
Amount of fat necrosis you're going to have to figure out a way to manage this.
This is probably gonna be, I guess maybe shared decision making right where you pretty much
talk to the patient and like some of the previous speaker said you either convince them
that it's not that big of a problem and you don't need to do more surgery or it is enough
of a problem and then you do have to do something in order to intervene.
Especially when you're talking about a breast cancer population,
the presence of any new nodule that they feel is gonna be of some concern,
right, because it's a breast cancer patient.
So for almost all these patients, what this entails is a lot more of a work up.
You have to send these patients to get imaging for ultrasound.
If ultrasound sees anything that looks even remotely suspicious or patients say they want
to know what it is, now you have to coordinate the patient to get a biopsy even though the
overwhelming. Majority of times we know this is probably
going to be something benign that's fat necrosis, but again,
you know, anybody in the room obviously who treats breast cancer patients,
you're going to encounter this phenomenon whether it's something that was caused by your
surgery, your reconstruction, or even sometimes the mastectomy because we do see fat necrosis
that remains and lingers in the mastectomy skin flap or you see it after radiation,
this is a reality that we all face.
This is a large area of fat necrosis in a patient.
Who had undergone a breast conserving surgery then had postoperative radiation,
similar circumstance, patients who have whole breast radiation and again this may be somewhat
unique to my institution, our radiation oncologist, no offence to the radiation
oncology room, they do not care about what they cause.
Fat necrosis not their problem.
They will radiate people very aggressively, so we see this problem not infrequently.
So after patients get their.
Breast conserving surgery, they have a generally nice result,
but then radiation happens. Now you have to deal with the aftermath of fat
necrosis, contractures, and loss of volume.
So again, I think anybody in this room who does autologous fat grafting,
this is a very, very useful and important technique for enhancing the results after
patients undergo a type of resection, whether it be a mastectomy or breast conserving surgery.
There's a lot of different products out there.
Sure there are many more than what's sort of presented here.
These are all available sort of in the United States and again the decision for which one to
use is very surgeon dependent and again there are a lot of different studies looking at which
technique may be better versus another, and there's different things that you want to
consider in one regard you want to look at the efficiency, how much fat graft do you actually
get per time spent harvesting.
How do you want to process the fat to remove some of the contaminants?
Historically, the stromal cell fraction was viewed as a contaminant.
You want to remove that, but newer data would suggest that there's more stem cells and
potentially growth factors in that fraction that you may want to actually preserve and
include in your fat grafts. So again, there's a lot of different factors
that come into play when you're doing fat grafting.
It's not just getting fat out and injecting it.
and again I think in the interest of time a lot of our previous speakers don't touch upon the
details of it, but their technique and their experience is critical and minimising the risk
of having problems with cysts and and fat necrosis.
So again what we looked at is sort of this is unpublished data,
but we looked at sort of different processing and harvesting techniques and you could use a
technique which is a filtration. Device the revolve is sort of a handheld
centrifugation or probably the most well known common technique is the Coleman which is just
centrifugation and what we found was actually based on the volume per
millilitre of fat, you actually had more viable adipocytes when you had
the simplest way of processing the fat graft so. Again, this is sort of borne out also
the less trauma you cause to the fats during your harvest and probably the less trauma
you cause with processing, the higher the viability of your adipocytes and more likely in
that scenario, the lower chances you're going to get fat necrosis and oil cysts.
So again, I think when you're managing this large amounts of fat necrosis and cysts.
You have to operate on or you at least you owe it to your patient to biopsy or investigate
smaller ones again if patients um don't really mind that much share decision making,
you just tell them no big deal, they'll be fine, they'll be OK.
I send them to Doctor Nahabidi and for more evaluations in in the future.
But really I think the critical aspect, um, is really prevention and again I think many of the
speakers can give you sort of their tips and pearls about how to avoid.
Oil in fact and again you heard them talk multiple sessions.
Why do you do multiple sessions? You do multiple sessions by far and large
because you don't want to inject a significant amount of volume,
you know, 1000 ccs, 800 ccs. I'm even more concerned.
I won't do more than probably 100 and 120 ccs in any setting,
but again you sort of want to.
Spread out the amount of fat you're injecting over time which again to try to maximise your
your fat graft take. So it's just a technique that we use.
It's completely sort of avoids any processing.
You're just liposuction.
It's a closed system so you're trying to avoid contamination and again you harvest it directly
into a bag. It's just decant it to remove the fluid and the
sin solution and then you inject it back in completely a traumatic and a closed system.
I'm really thrilled about what I've done, but again, the concept is you're not traumatising
the fact that you're harvesting and again it works well,
at least for me in my hands, small volumes, multiple sessions as needed.
Um, here's a young patient who has a lumpectomy from the left side.
we did a little arcoplastic reconstruction. She's a little bit short on.
Volume and again with a little bit of fat grafting against small volume we're able to
sort of fill out the upper pole for and achieve a reasonable result without incurring any risk
of fat necrosis or oil cysts. Here's another younger patient,
obviously very aesthetically astute. She's got a very nice belly button ring that I
have also, you know, it's really sexy, but you know she undergoes a resection and now has a
contour deformity in the lower pole, and again this oftentimes just gets accentuated after
radiation. I would agree that the the use.
Of the fat grafting, I suspect it's an issue with stem cells and the benefit of the stem
cells that improves the tissue recovery after radiation.
And again, I tell patients if you're going to have fat grafting,
it is multiple sessions because I don't do a large volume in any one setting and again you
know she wanted an augmentation, so this was an opportunity to get free breast implants um and
again we did some fat grafting and try to correct the lower pole um again uh as uh you
know, most people in this room, I'm not nearly. Talented a micro surgeon as some of the other
uh uh esteemed colleagues in fact that we have, but I do uh free flops more often than not.
So if there's a problem, there's no chance I'm gonna get as nice of a result with fat grafting.
So for a patient with a previous abdominal plasty, we do stacked paths and again you can
enhance the result with the fat graft. I would,
would not have the skill to do a full breast reconstruction with fat grafting,
but again, multiple sessions, smaller volumes.
You want to try to do things to. maximise the fat graft take and again avoid the
risk of fat necrosis and oil cysts when you're talking about autologous breast reconstruction,
you can obviously also develop fat necrosis in your flaps and again,
the different technologies that we use nowadays in order to try to optimise the perfusion to
your flap. So for me I never base a flap on a single
perforator because I'm not nearly as talented and I think again you want to try to maximise
the perfusion to the flap.
minimise the risk of fat necrosis because fat necrosis results when you have poorly perfused
tissue. So again this is endocyanine green.
This is a clear demarcation where the perfusion is not optimal that needs to be removed again,
you want to do this to minimise the risk that you're going to develop fat necrosis in the
long run and again you want to use the ICG. You can look at it on both sides.
It's not just the skin that you're worried about.
You want to look at look at the. Underlying fat again to make sure that the
tissue is well perfused.
So again for a patient undergoing a modified radical mastectomy,
we can do the reconstruction we do the ICG to confirm excellent perfusion of the tissue and
again sort of postoperatively you want to make sure that the tissue is well perfused to
minimise the risks of having anat necrosis and again this tissue where it's marginally
perfused, should probably be excised and again postoperatively you can give patients a fairly
reasonable. and minimise the risk of having fat necrosis
along the same vein to maximise perfusion of your flap and avoid the risk or minimise the
risks we oftentimes will take both pedicles on a deep flap in order to make sure that
the perfusion is good.
So um again for a larger breasted patient, um, you know,
we use the ICG, the entire abdominal tissue is harvested and again you can use all that
vascularized tissue to reconstruct a unilateral breast.
In order to make sure that tissue is all very well perfused,
um, so sort of in conclusion, I think panros and oil cysts are somewhat inevitable and
oftentimes what we do, but again I think a lot of the techniques that we use in terms of
harvesting, injection, and the number of sessions that patients take can really avoid
the and minimise the risk of that happening and again uh we'll sort of go into probably the
autologous reconstruction in the future, but um I think there are ways to prevent and minimise
the risks of fat necrosis when we're talking about free flap reconstruction.
Thank you so much again.
OK, I think we're reasonably on time. I would like to ask everybody on the podium,
and there must be a tonne of questions over here.
Yes
Thank you so much for the panel, right, I have a question for you on your,
uh, cryopreserved fat. Actually I have two questions.
Number one, when you collect the fat and that is transferred to the lab,
how does the process happen? Is the fat placed in.
And a special solution is in a special container um before it goes to where it's gonna
be cryopreserved.
Then I can tell you what I do. I put in the bag.
I give the bag to the the the staff of the company and uh uh is,
is put in a special container just for uh to be freeze immediately because they have to,
uh, they do 2.5 hours uh of journey.
I don't know because there is a patent behind it that I don't know how it's treated because
they are they are the only one until now that they were able to give you back the uh the the
fat with a certificate that how much uh uh survive stem cells you have,
uh, and the comparison between pre and post.
Pre observation, then I don't know how it's treated.
I can tell you that um it depends where I have to use it.
Uh, may I have more fluid or more density of fats, then they,
they do for sure something, but I, I, I actually don't know what's the,
the treatment because it's, it's under a secret.
Industrial, you know.
So it's pretty fast. The transportation between the time that you
harvest to the cryopreservation is that a lag maximum lag time that you can,
let's say if you finish harvesting fat at 5 p.m.
and you come next morning to get the fat they are they they are in in just outside the,
the OR when I start to do the surgery, then it's immediately put on the freeze.
Thank you. Hi there.
Uh, this question comes from our online attendee, Quentin Roo from the Netherlands,
who asks, previously there's been been suggested that the addition of lidocaine to
infiltration fluid might reduce fat cell survival.
This is this thought still standing, or can we harvest fat safely using standard liposuction
fluid under local anaesthetic?
It's the question. For the panel?
Well, we investigated the 1st 2008, the influence of local
anaesthetics upon of fat graft, and it
was worldwide the first publication.
If you have, it kills the cells.
Pen is very cheap and very common in hospitals, but you have a lower retention rate.
But if you take the lidocaine with a solution with nothing happens.
You can't use it. It's been published in 2008 in Canada.
Other questions? I have a question because essentially you
didn't solve. My question before that, uh, so we're speaking
about volume retention, but essentially which kind of cells,
because Roy spoke about stem cells, somebody speaks about fat cells.
Essentially, if you have 1 11 million.
Cells to begin with, how many cells do you keep and which cells do you?
Well, we graft a quarts of 0.5 1
millimetre. They have a higher survival rate.
We could also show that in the mice model that they are revascularized after.
5 to 10, 5 days, 6 days.
And We have measured the outcome of the survival with MRI control.
We take an MRI before, after half a year, even after with some patients after 5 to 9 years,
and with an MRI you can do it very exact plus minus 2%.
And the effective survival rate of the fat cells was about 75 +
minus 10%. But this is cell survival or volume survival,
volume survival, but if you watch it at 5 or more years,
then you can see with the increased weight it's not only volume but the fat is growing.
It can increase up to 3 cup sizes of breast volume.
And I've measured it for we infiltrated the pectoralis major muscle,
and an MRI you can sort out the muscle volume and see the muscle without fat,
the muscle with some fat after half a year, and then after 5 years it's increased a lot,
so it's living and growing fat.
And I think there's an interesting fight over here also because Ramon is,
uh, was talking about how he treats his fats. He does enzymatic dissection,
mechanical dissection, and then we have Ed who says don't touch it,
and, uh, and you know it's it's still standing there.
Let me, let me try to solve that Andrew and thank you so much,
I mean. What what I think it is interesting is that you
know we seem to be addressing a quite a trivial question how many cells we have in fact graph
we're gonna fact graph here there whatever, OK.
Yet we can use this to answer fundamental questions in tissue repair and maintenance.
So I just want to point out to you that you know the enzymatic fraction,
the amount of cells that we are able to dissociate out of fat by enzymatic means.
It kind of arranges only 10% of those 11 million cells.
So all this literature that is present and accumulated over the past two decades about the
fact that oh the stromovascular fraction, the enzymatic fraction of the of the adipose tissue
is that much represents the total amount in quantity and quality of the cells that
populate adipose tissue needs to be corrected.
We have examined the tissue residue of both enzymatic digestion and mechanical
digestion and against all odds the viability of cells after mechanical
you know dissociation through sheer force is exceptional.
And we have, you know, challenged all laboratories on that and they have come up with
the same conclusion.
So the fact the adipose tissue is a far more physically resilient tissue that we anticipate
it, uh, you know, sustains and resist a lot of physical attraction and injury.
And it's maintained viable.
So with that what I'm trying to say is that we inject a significant number of
cells whether these cells are in quantity and quality not sufficient for establishing a
repair that maintains the volume that's a different story.
May may have something that is, uh, I think that we still doesn't know everything,
uh, in, in Italy we are doing the study. It's, uh,
Gino Rigotti and me, you know, everyone knows Gino, and because Gino is doing uh a total
breast reconstruction with fat and I'm doing, uh, a secondary with implant.
But what we are It is quite strange where we are seeing is that
the the fat, the clearer of fat.
It seems to work better than the fresh one and we are trying to,
to demonstrate and we are studying the thickness and the intake and everything.
I, it's difficult to explain actually how it's possible more or less we do the same,
probably I don't know it seems like the, the, the, the fresh fat is astonished by,
by, by the, the, the other thing I don't know, Roy.
What, what happens is that we all, I'm I'm sure all we have experienced this we go into the
OR we're giving a syringe and we begin to implant the fat graft.
You know, of course, you know, um, a cryopreserve lipo aspirate will go
in smooth, so the volume restoration index intraop.
It will leave us a very good soft sweet taste, you know,
it, it goes in smooth and nice.
The question is, and that is being posed by Ed, what happened to this beautiful
volume that we have achieved intraoperatively nine months later?
So the oil cs, the fat necrosis, you know, goes under, um,
under diagnosed for. About 6 to 9 months where the chronic
inflammation ring around that all cyst persist is no longer mask but the chronic
inflammation all around it and now we palpate it most importantly the patient palpates it or
even can be observed then all alarms are set off, especially in the breast cancer
reconstruction field where oh we got a lump is that a recurrence we need to work it out.
And you know oil cyst is a reality.
Whoever says that does performs that grafting without oil cyst,
excuse me, but it is faulting to the truth.
But you see, are common in reconstruction, but usually it's palpable under
59:58.010 --> 01:00:04.919 the skin like a little pea, and you can only go in with a big cannula and extract it.
01:00:05.449 --> 01:00:07.729 But larger ulcers, if you have the right.
01:00:08.334 --> 01:00:14.415 Even, even, even more than that, I had some patients that taught me a very kind of a very
01:00:14.415 --> 01:00:19.695 kind of a cool trick, you know, doctor, doctor, I have this little lump in the upper outer
01:00:19.695 --> 01:00:22.844 quadrant of my breast that's where you just put a little bit of uh.
01:00:23.270 --> 01:00:26.159 You know, yeah, yeah, well, we're gonna have to work it out.
01:00:26.250 --> 01:00:28.760 Oh no, no, don't worry about it don't worry about it,
01:00:28.850 --> 01:00:35.010 you know, call in uh her husband, and you know please show the doctor how you kind of deal
01:00:35.010 --> 01:00:39.489 with these lumps. So the husband goes leans over the patient and
01:00:39.489 --> 01:00:43.919 begins to squeeze this lump as I've never seen this before,
01:00:44.209 --> 01:00:51.010 you know, and all of a sudden it was very clear that the oil cyst did pop.
01:00:51.729 --> 01:00:54.229 Yeah, that's an alternative. Well.
01:00:55.800 --> 01:00:59.429 I'm at a loss. I mean, I don't know how, what am I gonna do
01:00:59.429 --> 01:01:03.860 now, you know, now of course this is just a joke and it's not a joke,
01:01:03.939 --> 01:01:10.860 it's a reality, uh, but, uh, you know, uh, uh, I'm far away from recommending popping OCs left
01:01:10.860 --> 01:01:14.939 and right, um, uh, rather, uh, you know we that needs.
01:01:15.044 --> 01:01:18.264 Could it, could it have something to do with the fact that,
01:01:18.514 --> 01:01:21.665 you know, I have a very good friend of mine. He does fat grafting and he does it.
01:01:22.114 --> 01:01:28.435 He just pulls the fat to a gauze and, and does it completely open into the oxygen and oxygen
01:01:28.435 --> 01:01:33.155 is very toxic, and then we have this cryopreserved and the thing that it does this
01:01:33.155 --> 01:01:34.344 completely closed system.
01:01:35.465 --> 01:01:37.274 It because we talk about the, the.
01:01:37.729 --> 01:01:42.310 The perfusion of the fat, the fat grafts, but it is not the oxygen tension in the air which
01:01:42.310 --> 01:01:47.020 is extremely toxic which could partly kill your result, yeah,
01:01:47.110 --> 01:01:48.350 and this is a good thought.
01:01:48.669 --> 01:01:51.949 we're basing the scientific thing, but fat defeats that,
01:01:52.229 --> 01:01:57.179 you know, we have in the laboratory what we call a fat cellar just like you,
01:01:57.189 --> 01:01:58.899 many of you have a wine cellar.
01:01:59.110 --> 01:02:03.030 We have a fat cellar in our lab and these are lipo.
01:02:03.475 --> 01:02:07.385 samples from different days, you know, not years, of course,
01:02:07.675 --> 01:02:14.245 uh, uh, and then we just go and pick up samples of this fat that is kept at 4
01:02:14.245 --> 01:02:18.705 degrees and we can tell that the viability of the adipose tissue,
01:02:18.955 --> 01:02:25.395 at least the cells in it, we stand 10 days at 4 degrees, you know,
01:02:25.635 --> 01:02:28.475 about 5 to 7 days at room temperature.
01:02:29.209 --> 01:02:36.080 So and when you realise the metabolic demand of uh fibroblast from adiposite
01:02:36.080 --> 01:02:42.169 is uh you know, the metabolic demand of a fibroblast out of adipose tissue is about
01:02:42.169 --> 01:02:47.679 4 ico per litre per minute.
01:02:48.050 --> 01:02:53.739 Uh, now that doesn't mean anything to you, but if I tell you that a hepatocyte uses 40.
01:02:54.330 --> 01:03:01.330 Then you begin to realise what is the low oxidative metabolism required but by an
01:03:01.330 --> 01:03:06.280 adipocy uh by a fibroblast, you know, in the adipose tissue,
01:03:06.530 --> 01:03:12.899 which means that makes that cell quite resilient to hypoxia and to hyperoxygen.
01:03:13.719 --> 01:03:15.600 Well, you know, um.
01:03:16.729 --> 01:03:23.389 Again, the viability is quite uh striking in these cellar samples,
01:03:23.800 --> 01:03:28.850 so the oxygen, the outside oxygen with a partial pressure of 21.
01:03:29.629 --> 01:03:33.370 It's not affecting the adipose tissue viability.
01:03:33.620 --> 01:03:37.689 Do you think that against all odds, you know, I can assure you that right.
01:03:39.780 --> 01:03:43.649 Do you think though that the stem cell fraction is a little bit more sensitive?
01:03:43.899 --> 01:03:47.810 We've often found that uh the adipoy will tolerate a lot more,
01:03:48.219 --> 01:03:53.899 but to Kuon's question, the distribution, the percentage of stem cells from one patient to
01:03:53.899 --> 01:03:56.459 another in any given sample will be very.
01:03:56.810 --> 01:04:01.679 Variable right factors dependent on age exposure to other elements,
01:04:01.689 --> 01:04:06.739 use of statins and different drugs which can elevate or change the stem cell component and
01:04:06.739 --> 01:04:11.850 the proportion within an adipocyte, but the stem cells do tend to be seem to be much more
01:04:11.850 --> 01:04:15.060 sensitive. They tend not to tolerate an extensive amount
01:04:15.060 --> 01:04:18.810 of time in cryopreservation or sort of transport and,
01:04:18.820 --> 01:04:23.419 you know, the other potential factors that the adipocytes do tolerate.
01:04:25.310 --> 01:04:29.629 Um, I'm sorry to his end.
01:04:30.399 --> 01:04:37.110 Um, uh, uh, uh, stem, the, uh, the stem cells that is the progenitor preadipocy
01:04:37.110 --> 01:04:43.300 non-specified species in the adipose tissue are is quite resilient,
01:04:43.790 --> 01:04:47.949 is quite resilient, in fact, far more resilient than the mature adipocyte.
01:04:49.750 --> 01:04:55.370 Um, it's, uh, they are there, we're not using it right.
01:04:56.149 --> 01:04:57.719 But they are there.
01:05:02.350 --> 01:05:03.530 Any more questions?
01:05:07.159 --> 01:05:09.270 The recipient site. Yeah.
01:05:10.850 --> 01:05:14.709 Well, like, uh, Roger Corry's, you know.
01:05:15.669 --> 01:05:17.189 Uh, Curry's, um.
01:05:18.429 --> 01:05:24.439 Um, external, uh, negative pressure, uh, increases the interstitial space.
01:05:25.709 --> 01:05:32.149 So it seems that the interstitial space it uh it it is a good change
01:05:32.149 --> 01:05:36.810 uh preemptive manipulation of the recipient bed.
01:05:37.629 --> 01:05:44.510 In order to accept better and more fact grafting, at least more fact grafting,
01:05:44.889 --> 01:05:50.280 but if you kind of uh remember one of the slides that I presented in the first day.
01:05:51.110 --> 01:05:57.929 Uh, yesterday, you know, one of the slides was an an on Delvecchio
01:05:57.929 --> 01:06:01.290 and Cory's case on his own raw data.
01:06:02.489 --> 01:06:09.479 And the fact that even though you increase the capacity of the recipient bet with
01:06:09.479 --> 01:06:16.479 negative pressure at the very end, the retention index at 9 months
01:06:16.949 --> 01:06:18.520 does not correlate.
01:06:19.379 --> 01:06:26.239 So no matter how much fat graph you put, you know, there is not increment in
01:06:26.239 --> 01:06:27.280 volume retention.
01:06:29.030 --> 01:06:31.070 With the negative pressure.
01:06:31.879 --> 01:06:38.439 And you have to wear the brava right into the OR because if you take it away one hour
01:06:38.439 --> 01:06:42.149 before everything deflates, so there's no permanent results.
01:06:42.310 --> 01:06:45.629 That's why we do some infiltration of the breast.
01:06:45.669 --> 01:06:49.459 We have the same effect. I've tried it several times.
01:06:49.580 --> 01:06:55.469 The patient completely devastated to the OR, adds to the cost,
01:06:55.590 --> 01:06:58.429 so I don't think there's advantage.
01:06:59.110 --> 01:07:03.989 Anyway, um, I think we're just on time and thank you very much to all our speaker for a
01:07:03.989 --> 01:07:05.310 very interesting sessions.