These are my disclosures and I'd like to take a few minutes actually to talk about the journal
and introduce it to those of you who are not familiar with it.
It's continued to grow, and one of the largest number of submissions,
in fact the largest, is to the breast section.
Our uh impact factor continues to grow and we're truly an international journal with
more international submissions than those from the US and even in terms of acceptance,
the international has a slight edge.
uh, I'm proud to say the United Kingdom has one of the highest acceptance rates for the
Journal. My term ends at the end of this year and I'm
happy to say that Jeff Kinel, who's an educator and a scholar,
will be taking over, and he and Mona Harbiian had the foresight to
establish a section on aesthetic breast reconstruction, and it's already getting
flooded with submissions, so we encourage you to give our journal a look for aesthetic and
reconstructive papers.
So this is my topic and my personal observations.
Forgive me if I don't mention you or your mentors as game changers.
My journey started as a general surgery resident when I watched Paul McKissick,
who at the time was thought to be a game changer, but history hasn't been kind to him.
He had this vertical.
pedicle and I looked at him while he was operating.
This is what he did.
The inferior it's an inferior pedicle with a dermal superior pedicle.
So what have I learned? I learned that everybody believes in a dermal
pedicle, and he did what was called the wise pattern to shape the breast.
And I started digging. I found this paper from 1960,
Strombeck. He did a dermal pedicle, but it was a medialy
oriented dermal pedicle.
So what did I learned before I even became a plastic surgery resident that it was all about
nipple areola.
Viability the dermal pedicle was in and I heard the mention of wise pattern.
who was wise? He was a Houston plastic surgeon who came up
with this pattern which he based on this bra, and I saw a lot of senior surgeons cut
it out of X-ray.
Material, put it on the breast, draw the lines and operate,
and this is a very good 2 month result. I don't know of any journal today that would
take a 2 month follow up.
That's from his.
The the other thing that I've learned over the years, a lot of people refer to the inverted T
as the wise pattern.
That's not the wise pattern.
So to the best of my knowledge, there's no data to establish superiority of any
technique or pedicle or data are level 5, expert opinion,
procedures feel by the way fall by the wayside based on the popularity.
Of the proponent rather than EBM Level 5 expert opinion,
revered well-known surgeons, wanna be game changers influence our thinking,
and this was the true with McKissick. Nobody's done the McKissick procedure.
I never did one and I bet some of you never even heard of it.
So we tend to describe breast reduction either by the pedicle we base it on the scar
or the name of the person.
So this is my first game changer.
Leasir Ribeiro from Rio published his inferior pedicle reduction,
and Steve Mathis and I as residents in plastics got to scrub with him.
And what he did was to shape that inferior pedicle and then suture it to the
chest wall with this 6 month result in PRS.
He then later wrote up a 30 year experience.
The images are much, much improved.
You can now tell what he did with this inferior pedicle, stitched it to the chest wall.
And then in this paper he showed a 10 year follow up,
much better images as well.
Ruth Graf and Tom Biggs based on the work of Daniel.
popularised the placement of that inferior pedicle instead of suturing
it, putting it below a loop of pectoralis, but what I give
them credit for is they start going away from the dermal pedicle.
the dermis, so it was more mobile scientifically basing it on the vessels that
came through the breast tissue and not on the dermis, and then many others went on to
describe internal flaps that were superiorly based, laterally based,
or a combination.
And although these flaps improve upper pole fullness compared to no flap,
with time, all of them descend and admittedly a lot of the papers today are published on
massive weight loss patients as is.
This one with Leasia Ribeiro is a co-author, uh, suring and folding that flap on
itself. But 220 again from Brazil looking at the
Ribeiro operation, putting clips on that flap and then following it and seeing that the clips
descend, the flap descends, so there's no proof that these tissues stay
where we put them, but we already knew that clinically.
So the next, for me, game changers were two big names at the time.
Eugene Curtis and Robert Goldwyn Goldwin eventually became editor of PRS.
They published this paper in 1977, which became very popular in the US,
influenced us all to do the inferior pedicle as they
popularised it, and this is from their paper in PRS.
I'm glad to say that we don't see these long scars again.
Uh, more today, so based on the work of uh Ribeiro, Curtis,
Goldwin, the inferior pedicle technique became extremely popular in the US and actually
was the workhorse at Emory, uh.
To me, another game changer, mentor and a very good friend was John Boswick,
who reintroduced and popularised the latissimus for breast reconstruction.
He and I continued with the inferior pedicle.
I'll come back to Rod Hester, in fact. We even wrote a paper in 1980,
avoiding the flat breast and reduction mammoplasty, a paper that I don't think today
any journal, including ASJ would even accept what we did,
and it's shown nicely here, the inferior pedicle leaving the nipple on it.
And suturing it to the chest wall and we have a 10 month postop result there
with awful scars instead of being in the from mammary fold it creeps up on the breast.
I like to say this must have been Steve Mathis or Hester's case.
It's probably mine.
He went on to expand on the inferior pedicle, called it a central pedicle
technique, and actually published this 4 year result in PRS,
very good looking result.
Rod has retired. This is his case.
I have his permission to show it and critique it because I found this very.
Educational.
If you look at this result at 6 months, it's beautiful.
Yes, the scars are a little hypertrophic, but then look at what happens at 18 months.
Everything descends. Everything descends.
I used to tease Rod and say, well, you know, you should have put the nipple a little lower,
and the patient would be happy and no one would say she had bottomed out.
So I continued with the inferior pedicleribero flap.
I was happy with it, as were most of my patients, but in 1995,
I chose to try the Lass operation.
To me another two game changers, Madeleine Laure actually is a great game changer in many
ways, one of the first and one of the most leading female plastic surgeons in
Europe. I met her in 1979.
She introduced me to Claude Lase. I became familiar with Claude's work,
which was the vertical mammoplasty of.
Dartigue and Madeleine went on to modify Claude's operation,
but it took me 15 years before I adopted the superior pedicle short
scar technique.
Why did it take me 15 years?
Because I thought I was happy with my results, I must admit I had little familiarity with
pedicles other than the central and the inferior.
So in 1995, 1996, I started with the Lass
operation and I've been pleased with it.
This is typical of my results with the Ribeiro technique.
Uh, I thought this was good, my patients thought these were good,
and this is typical result with the Claude Lasseus.
Much more projecting more apropole fullness and results that lasted longer and Rod Hester
used to come in and say, Are you operating and making more torpedoes?
and I said they may look like torpedoes to you, but they maintain the shape.
So this is this was a difference in my hands with the inverted T and an inferior pedicle
and a superior pedicle and a short vertical scar.
The next two slides I put together about 4 or 5 years after I adopted that operation,
and it had everything to do with who's a candidate for a short scar and who isn't,
and I felt that a full envelope, normal skin elasticity and skin adhering to the breast
tissue were what I would take into account. Today I add whether I was dealing with a fatty
or a fibrous breast, so these were good candidates.
And today I'll say these are good candidates who would maintain their result over time,
whereas these were poor candidates, empty or partially filled envelope,
poor skin elasticity and skin that's not adherent to the underlying tissue.
So the debate and the discussion at the time were what do you do?
OK, you've got this shape here and again I want to emphasise maintaining the inframammary fold
and I'll come back to that.
What do you do with the skin that's left?
You have 3 options and it doesn't matter what you choose to do,
it won't affect the shape and it will significantly reduce the scar anyway.
To me, I felt that if we're removing central and inferior breast tissue,
bringing those pillars together, then we we were a reducing
the base of the breast and then pushing up the nipple and uh.
Areola, I don't know if this is gonna, can you see if the video will play?
I don't know if I have to, uh, click on it again.
It was playing this morning when we went through it.
Anyway, the key here is to preserve the inframammary fold and I I'll,
I'll go without the uh without the video.
Initially they all look exaggerated. They look like a torpedo full up a pole,
empty lower pole, and it brings me to Patrick's discussion about stretching the lower pole.
They do stretch, and I'll show you more examples about how they eventually settle.
What I learned along the way was that yes, you make an access incision,
you resect tissues, you resect skin, but what I learned is how you reshape that breast is what
counts not not only in terms of the aesthetic appearance of the breast but also in terms of
long term results.
I'd be remiss if I don't give credit to a couple of other game changers,
uh, Ollie Asplund and Di Davis from the UK were first and then followed by
uh. Betsy Hall Finley popularising the supramedial
pedicle which has now surpassed all pedicles in the United States.
It surpassed all pedicles at Emory.
Everybody's doing the supramedial pedicle with different patterns of skin
skin excision. So to me those are two other game changers.
Another one is Elizabeth Warringer and others that introduced us to the.
Concept of septum blood supply to the nipple areola.
So we've come away from fancy dermal pedicles to keep the nipple areola alive.
We now know the anatomy and with the septum we can keep the nipple
and areola alive regardless of what pedicle regardless of how large that
breast is and how much breast tissue.
I'm gonna show you some typical long term results.
I'm gonna show you the.
The good, the not so good, but I didn't have, uh, but I I'd like to think that I don't have
any ugly cases.
uh, now this one short scar over 2000 grammes from each side,
but it was solid breast tissue.
So it was easy to reshape and easy for the uh breast to keep its size.
I'm not showing you anyone with less than 2 years and up to 4 years uh to follow up on all
of these. So this was a superior pedicle, and when we
look at her in this view, she's maintained that uh what is it
45, 55 uh shape just with a reduction.
Here's another one, not as large a breast but again fibrous,
so superior pedicle, short scar vertical without any any inframammary fold,
and you can see that she has a very projecting breast as opposed to the flat ones that I
showed you when I was using the inferior pedicle.
I learned a lot from this patient.
I took one look and said there's no way I'm going to do a superior pedicle,
and then I thought central pedicle, no inferior pedicle, no maybe maybe
a free nipple graft, but what I did with this patient was to.
Measure the nipple to the IMF, and I was taught and I go to conferences when everyone says,
oh, if nipple IMF is over 36/38, you have to do a free
nipple graph. So I took that measurement and then I took the
measurement between the inframammary fold and decided how far that nipple and
areola has to move. So to this day, I no longer rely on.
Sternal notch to inframammary fold distance.
I I measure the distance that nipple has to move so that it's right over the inframammary
fold. So with this one I said, OK, no way that I can
still do a superior pedicle.
I went back to watching McKissick operate and I said, Well,
I don't need to do a dermal pedicle, but I can do a combination of a superior central
and an inferior pedicle, and there's that patient on the table.
She is a massive weight loss patient.
I did not resect any tissue.
I did not.
Violate her in mammary fold.
Why did I deepithelialize?
Not because I felt it would preserve the blood supply to the nipple and areola,
but because it gave me some tissue that I could suture together
almost like a mesh, almost like ADM to support that that breast.
Yes, her nipple and areolas are too large, but that's a 21 month result,
having shaped the breast, and yes, I did end up with a completely vertical scar.
I'm cheating a bit because she put on some weight, which makes the result look a little
better, but it became my workhorse for the typical mommy makeover as in this patient with
one difference.
She's flat here.
Why is she flat there?
I learned that it has everything to do with the footprint of the breast.
She had a different footprint regardless of what I do,
and there are a few things we can do.
It's it's not the upper pole won't be full and what we do today and if I had to do this case
today, I would fat graft that upper pole, but this is from about 20 years ago.
These are some typical examples where the upper pole has remained full,
the projection has been maintained, and obviously the smaller the breast,
the more fibrous the breast, the better the long term results.
And we we use the same auto auto augmentation uh credit goes to a lot of
people. I credit Madeleine Lejour, who was the first
person to show me how to do this.
And again, another thing that when some of the residents saw me doing this.
When I made that incision there, oh, doctor, is that flap gonna survive?
I said, you know, forget the dermal pedicle. It doesn't exist.
It's all coming in from below from the septum.
So this was one of the earliest uh auto augmentation mastopexy I did,
and the reason that I show her is this yes, my tissues didn't stay where I put
them. They descended.
But by descending and going from this to this and filling up the lower pole,
I think that's the key to the superior or supramedial uh.
Procedure and I usually show the patients this and turn it upside down and say this is how
you're gonna look for a few weeks or months and then I turned it upside down and say when
that's gone that's how you're going to look.
So here's a typical patient at 1 year, 4 years postop and.
Comparing the 1 and the 4 year post-op with the uh with the auto augmentation.
So what's new now, uh, not so new fat grafting, and that's one of the
things that I like to use when with a mastopexy, uh, even a reduction if I'm not happy with the
upper pole, I'll put fat in it.
I didn't mention breast augmentation because that's being discussed today.
Uh, measures are new, uh, where do we stand.
Our mesh is new.
My good friend Joo Sampaio goes from Sao Paulo, Brazil.
2003, he talked about what he called a mixed mesh which was
partially it was a combination of absorbable and permanent material that was woven
together. So and in this article in ASJ 2003,
he showed two and four year results, and this is what he did after he had lifted
the breast, he would wrap the entire breast with this mixed mesh.
You can see he had proof with uh histology that this does stimulate collagen and holds
it, uh, the introduction of uh.
It was called Galaflex then I'll come to the new name now.
I give credit to Bill Adams, uh, uh, and Bruce Van Natta.
Dean Torriomi is a facial plastic surgeon. What's he doing on that paper?
They used it in a facelift.
It fell out of use for faces, but it's still alive and well in breast
surgery and in this paper they had 12 and 24 month follow up with supporting the
breast in Mastopexy, the largest series to date, and thank you for publishing it in
ASJ. Patrick is now we call it P4HB, and I'm gonna
read Patrick's conclusion here.
Extremely versatile, easy to use, and low complication.
The results have led to a change in practise with routine incorporation of Galiflex for
routine mastopexy, but I think what's even more significant is his last statement.
It's replaced the use of ADM in aesthetic breast surgery.
ADMs were extremely expensive.
P4HB is affordable, so let's look at a little more of the literature on
bottoming out following Master PE C with synthetic mesh.
Despite reported relative safety and promising results, available data indicate measures do
not effectively prevent recurrentosis and bottoming out.
They may. Not be superior to describe techniques with
superior pedicle hammocks, balcony, but what they say and what I agree with,
we need well conducted study. Everything I've said to you today is level 5.
It's my opinion based on my experience, but I agree with these authors from
Lebanon who called for more.
Who who called for more well conducted studies like the one that we published in ASJ.
Here's another one from JPR Open Longevity of ptosis Cor correction,
and again I'm going to read through their conclusions.
mesh dermal sub suspension muscular slings showed promise in
providing. Support over standard techniques, no single
procedure is ideal for all patients, but this systematic review provides a valuable
description of techniques, uh, etc.
and I think I have one more from the literature, uh.
This one with Elizabeth Warringer's name on it and their conclusion is that
with the mesh, ptosis can be prevented in mastopexy reduction
procedures. The results are such that it eliminates the
need for silicone implant and the surgical technique is indicated in patients with poor
quality and patients with high expectations.
I thought all my patients had high expectations, but I'll come back to that in a minute.
So to conclude, 47 years, what have I learned?
What I've learned is that there's some things that I can control.
I've also learned that there's some things that are out of my control.
I can't, I can do nothing about it, I just have to accept it.
So I think there's a lot under my control. The pedicle I choose,
and I've gone from inferior and central to the superior pedicle.
What I resect, where I resect it from, how I put it together,
how I support the breast, but most of all, do not violate the IMF.
I'm a firm believer in the SFS system and.
I've gone from Sternal notch to nipple distance to judge and I've gone to the nipple
to the IMF distance to judge.
Now what's not in my control, patients tissues, and I already mentioned the more fibrous the
breast, the better the skin elasticity.
I can predict that they'll have a better result, longer result.
fatty or fibrous breast, I'd rather operate on a fibrous breast any time.
And I can do a little with the footprint of the breast because now we can fat graft it.
I just wanted to finish with a couple of my favourite slides and favourite uh papers.
Breast reduction is the only procedure that we do that treats symptoms,
and it takes a while when I say that to the residents.
They, they, they look at me as if, you know, is he getting old?
Is he losing his mind?
And uh I was criticised when I said this at the Atlanta and the Santa
Fe breast symposia that I consider all procedures on the breast as aesthetic.
As editor of a journal, I still consider it as aesthetic, but I was almost assassinated
for the insurance companies are going to grab this and they'll never pay for breast reduction.
Guess what? They're paying for breast reduction.
And this one from Bob Goldwyn again to me, a game changer.
The more the patient considers a reduction is reconstructive, the more likely she is to be
pleased, the more she considers it as an aesthetic procedure,
the less likely she is to be uh to be pleased and my final slide,
one of my favourite things, uh, you know, everybody says I'm an artist,
I'm a plastic surgeon to be a plastic surgeon you have to be an artist.
Well, I, I'm the voice of polite dissent. I.
I would much rather be a craftsman than be an artist.
Yes, an artist can envision it all here and have a vision for the result they want the
patient to have.
But if you're not a craftsman, if this can handle your instruments here to produce that
result, you'll end up.
Disappointing your patience and disappointing yourselves, so a craftsman is someone who
performs with skill or dexterity, and I think our skills and dexterity
surpass any vision that we have. Yes, we need to have a good vision.
We need to look at a patient and say, based on your tissues,
this is the shape your breast will look like, and this is how long I anticipate that it would
last. So what I'd like to do is to thank you for the
kind invitation, my first time at this great meeting.
I'm gonna go home having learned more and having learned some new material here,
so thank you very much.