So the way this session is set up is we've got 6 cases,
we'll try to get through as many others as we can.
Uh, the cases were all submitted by our panellists.
So what we're gonna do is we're gonna go to case 1.
Um, and as soon as it comes up, what I'll, so, so this is case one and it was
submitted by Doctor Rehnquist. So, um, Charles,
why don't you just maybe tell us a little about this patient,
uh, and everything that's pertinent, and then we can have a discussion about what to do.
So she came into my office, 20 year old anatomical macrotecture devices,
410, 350, as you can see.
Jet caps a contracture, right, 4, left 3, ruptured left implant,
fluid around left implant, severe symmetric press concerns.
About breast implant associated at that time when I operated her,
we didn't have a clear picture of ALCL.
This is a couple of years back, and at that time we took care of these patients ourselves,
which basically meant that we aspirated the fluid, we sent it away,
and then we had the answer, but we didn't have the answer,
so we basically did total capsulectomies out of fear that all of these were cancers.
Today, patients that do have seromas.
Uh, they are immediately sent to breast centre, so it's a different strategy today.
So she came in and of course that's a tricky case.
Uh, it was for me at least.
Yeah, so this is just the oblique views, yeah, and as you can see she has a very firm high
riding right side through both so.
Uh, I just wanted to share this, what would you do and what would the audience do?
I share the way we do now, we send it to breast centre, but all countries have different
philosophies and, and, and how do we act?
because this is a patient that might occur into your practise.
So Patty, why don't we start with you, somebody who's got fluid,
textured implant, you know, what are the current recommendations?
How would you manage this patient?
These patients, as Charles said, need to be evaluated prior to surgery.
I'll hear surgeons say someone comes in with a well I'm gonna do an unblocked capsulectomy
anyway, so I'm not gonna test this. I'm not gonna waste the time and money for that.
That's the wrong answer. If the patient does have ALCL,
the best chance of curing that patient is with the first operation.
So that patient needs to be evaluated ahead of time.
That fluid needs to be aspirated, needs to be sent for CD30.
Testing we now send everything also for CK 56 for squamous cell cancers and get the diagnosis
prior to surgery. So this comes back ruptured implant you
commonly see a seroma.
uh, I would do total capsulectomies on this patient, uh,
because she's had a seroma, she had a macro textured implant,
then you're left with a completely uncontrolled pocket, which is very difficult on these
patients, uh, so you're gonna have to have a plan on how you're gonna control the pocket.
Does she want implants back in anymore? Some of these patients are so spooked.
She's had hers for 20 years. She may not want implants.
Place you're gonna have a long talk with this patient, uh,
about what she wants to do and, and why, and, uh, then go from there for the next step.
And if you do operate on, take the capsule out the capsule needs to be sent for pathology any
fluid that you get as well also needs to be sent again for cytology and immuno
immunohistochemistry.
Mark, she had asymmetry. She had capsular contracture on the other side
and fluid on the one side. Would you do anything different to the other
side, or yeah, let's go back.
Um, well, if we're taking this as a, a benign situation, I mean,
it, it's, it's hard to add much more of what, uh, uh,
you said, and I think you've assuming then in this case she wants further implants
in, the architecture and the, the scaffold that the capsular contractors provided to the right
breast is going to be totally transformed once that capsule's out.
And we often have this experience, don't we, that retrospectively,
these are very difficult patients to manage psychologically because they almost preferred
their slightly lifted breast that was a result of the capsule in the inside.
And when they're getting their more natural, perhaps more symmetric,
but softer and often lower lying breasts after.
they're somewhat underwhelmed and disappointed.
So I think the key message that seems to be a repeated message from all of us today is about
that preoperative counselling and discussion and managing their expectations because this is
potentially in her mind, despite the capture of the contractor and the bit she doesn't like,
going to be a downgrade in some aspects. Dr. Montaro, anything to add?
I know you've had a lot of experience with the old biocells.
Is there any special considerations then in somebody like this in your practise?
How, yeah, sorry, I didn't hear.
So yeah, what I would do here, I mean, of course it also let's,
let's say that it's benign, so she doesn't have a diagnosis of ALCL.
What I think would be crucial in this case, um, is to have control,
uh, on the position of the so to me this would be a polyuretan case.
Um, I would probably use an anatomical implant that would provide the possibility to have a
slight lift, always providing the fact that the patient doesn't want to downgrade the size.
So if the patient wants the same size or slightly up,
then I think, uh, anatomical polyurethal implant could be,
uh, the best choice. Why don't we move forward here.
So Charles, is it safe to assume that she did not have ALCL?
Yes, however, with that said, We have a so-called IV clinic,
the National Breast Check Clinic, where we've seen more than 900 patients with ultrasound.
And one of the things we've learned and we're going to publish this,
is that although patients might have negative CD 30 stats.
The capsule might be positive. Now you would ask yourself,
what is that number?
It's actually in our study 3 in 30, that's 10%.
So with that said, If you do have a patient that comes to your office with recurrent
seromas historically, negative CD30 stainer.
The policy we have within our practise is that we perform total capsulectomies.
Which unfortunately is cancer surgery.
So in a case like that, Patty, where you would have done a capsulectomy,
capsule come back positive, would you go back and now do uh additional resection or would
that be? I think if you got the capsule, I don't think
you have to go back and take, you know, PEC minor or take any muscle or anything if that
caps. out completely and then the staging will have
to go. It depends on what the pathologist sees in the
staging if it's through the capsule that patient's probably gonna need some adjuvant
treatment as well, so that'll all just depend on what the final pathology shows.
OK. Uh, Eric, why don't you take this one.
So, uh, this is, um, case, um, from, uh, Marlene, oh,
also Charles, oh, Pablo, Pablo, sorry, sorry.
So this is a patient who had a history of, uh, augmentation mastopexy back in 2006.
This they he is uh mentoilliex implants. They went sub glandular.
She has no capsular contracture, and she is, uh, coming to see us because she wants revision and
wishes bigger size.
Any any additional comments Pablo?
Yeah, not, not really. I mean, of course, you know,
luckily it wasn't me doing this first operation.
It was many years before by some other surgeon and it's weird to see that the the breasts were
very soft, but everything looks really bad and I think that the most important thing to
underline here is just is that she absolutely wanted she wanted to do this surgery with
bigger implants.
So it's almost 18 years after the previous surgery, right?
No, no, no pregnancies, no, uh, other, no, OK.
So we'll go the opposite side. Ad adult.
What would you do in this patient? Boss
both the IMF, uh, just kidding, but that's exactly what I would do.
I would do a pocket exchange, go a muscular, and generally what I see after we really.
Uh, controlling the IMF, that patient generally doesn't need a bigger implant,
need a better position implant.
With a 256 breast implant.
I can get above the intellary squeeze, so that's how,
how we do, uh, uh, if I want my upper pole on the anterior.
Inter auxiliary grease level 200 cc's 1 centimetre above it 250,
2 centimetres above it 300 cc's.
I generally don't use more than that with my patients consider that then we change the
footprint to get the impression of a bigger breast with a smaller implant.
So I, I would do pocket exchange with a house scar.
Um, I, I'm sure, I'm sure Abel de la Pena has another approach.
Actually, this patient is very skinny and she wants larger,
um, implants.
So, uh, would you still, still remain sublanda or go to another.
Probably the first thing that I do is I send it back to Paolo so.
After if she if she doesn't wanna go all the way, so probably we have very different things
here. First of all, I mean each of, uh, each side of
the breasts are totally different, so we cannot compare the right side with the left side even
though they're they're not in a capsule contraction.
So we need to take care of the areola first of all, so she probably will need a masterpi in
definitely. And periareolar doesn't seem to be the right
way to go, so probably we'll need an extra incision in order to get a better position for
the for the breast.
Secondly, I'm in this patient that I she cannot go with the sub glandular space,
so she's a, a perfect candidate for a sub muscular.
And but not a standard sub, which means I mean if you go with a dual plane you will still have
a very few uh coverage for the implant in the inner part so probably we have to open
the, the, the pectoralis muscle, place the implant that usually in those cases use a
polygen cover implant.
That it's gonna be inside the muscle, but I will still have all the muscle around coverage
for the implant and the centre is gonna be open then we have to lift the areola.
We have to reduce the size of the areola and then you're gonna have a better result with it,
but definitely you need a scar in this patient.
I have a question. So you had mentioned.
You had mentioned earlier that you don't use scisors.
This is a woman who wants to be larger. Would you use scisors to see what was going to
optimally fit here, or would you have predetermined your larger implant?
So I came in in the with two implants, the right and the left implant that I had decided
before surgery. Do you know the thing with this patient,
what I told her, the first thing I told her is if you want larger implants,
I'm not going to operate. That's the first thing that I said to her,
because if you want me to be able to remove all those huge gigantic,
uh, um, areolas, then I have to downsize the implants just as simple as that.
And I'm gonna need to put the implants up muscular.
And again, the implants are gonna look smaller.
And she had consulted, I think, 5 surgeons, and she told me I was the only one.
Who told her that she couldn't go bigger that she had to go this and that and she chose me,
you know, I don't know why, but she chose me but the first thing I told her you can't go
bigger you have to do smaller.
You know, another way to approach a patient like this,
she's not seen her real breasts in 18 years.
I would take out her implants, let her see what her anatomy actually is,
allow that subglandular space.
To close down because otherwise if you're going so much you you're gonna need to put some mesh
or something in uh to to expand that out otherwise that implant's gonna pop right back
into this into the um subglandular space so I would take her implants out,
leave them out as long as she'll let me leave them out at like 6 months then she knows what
her actual anatomy is and then I would place it. Plants in a um submuscular position.
Charles got a question for you. This is just my own curiosity.
You got a patient like this big implant, a lot of pranal compression,
subglandular. Do you think there's more recoil if the implant
would have been subpectoral? And I ask that mainly because you've with a
subglandular, theoretically the pectoral fascia still on the muscle.
So you've divided those Cooper's ligaments. So are you going to get the same benefit of
recoil when you've already divided Cooper's ligaments?
No. Yeah, so simple answer.
Simple question, simple answer.
Surgical Anyway, why don't we go on to what was done?
Let's move forward just for time.
Uh, this is the same, this is the same, yeah, I think this is her post-op,
right? This is, uh, I think this is a 6 month follow
up and, uh, what I did is I just simply removed the implant.
I didn't remove any cups for tissue, just a little bit of the anterior part,
uh, just very little, and I did a dual plane. I didn't re-suture the muscle.
I didn't do anything. I did this surgery was pretty fast.
I think it was like, um, 1.5 hours.
And, you know, by downsizing the implant, I didn't, I forgot to write it here,
but I, if I, if I remember well, this is, uh, anatomical implant,
uh, foot projection 220. So, it went down from 2505 to 220.
It's a muscular and apexy. And I was able to remove the entire,
um, The entire area looks good.
Yeah, and 11 question on this, like when you uh reduce the areolar diameter,
did you Just deepithelialized? Did you score the dermis,
or did you undermine the skin in any way given that she was subglandular?
Similar question to what I asked Mark earlier.
Oh, no, actually, you know what I do, I removed the piti and then actually if you,
if you what I do is I use the the cory on a spray mode and when you buzz on the on the
derms it kind of shrinks. So that makes it a little bit easier to thermal
tightening, right? Yeah yeah.
So that's that's what what was done and this lady, she was so happy and I said,
are you gonna write a review to me? Yes, of course.
I emailed her twice and she didn't write anything.
Mm. OK, 3, this is uh Doctor Pacifico's case.
So Mark, why don't you go ahead and just give us the highlights here?
Well, I'm afraid it's a bit of a complicated one and um of course she was a friend of a
friend who it turned out, and I operated on her only 3 weeks ago or so.
So she had effectively a breast implant cripple, multiple surgeries,
uh, mastopexy, and then she describes various bizarre occurrences about dislocations of
implants. She um then went um.
Uh, elsewhere abroad for an implant exchange mastopexy and was persuaded to have a reverse
abdominal part at the same time.
She hated the outcome from the word go.
She then complicated her post-op recovery by falling down the stairs,
um, and go on to the next slide. I want to see the friend of hers.
Um, can you go to the next slide?
Great, and the wounds are hissed.
She was managed by WhatsApp, by the surgeon abroad to to get her healed,
which eventually did happen.
She then went to see a different surgeon, she was living in a different country then,
um, and had what she described as corrective surgery.
She describes what she said was the muscle separating from the implants.
She went back to surgery again um for what she described.
I couldn't get any of the details from other surgeons about the muscle being stitched back
in place, recurrence of various deformities, and then she went back to her final visit to
the surgeon on my advice cos as I said that there was a personal connection,
so I said it sounds like you really just need the implants out.
The other surgeon persuaded her not to have the implants out,
but to allow. Uh, to, um, have the implants placed,
um, from a dual plane, it sounds like to a subglandular position,
um, and then she presented to me, breast and I'm happy,
but certainly determined to have her implants removed.
So if we go to the next slide.
So here she is, um, I think what what you'll see, it's quite,
I don't know how well it projects, but the scarring's pretty terrible.
There's a a reverse abdominoplasty scars that extends beyond the crease.
If you go to the next slide, you can see some animation there.
Basically, the pockets didn't connect, but each breast could be moved to the contralateral site,
um, and there was just no stability or support for the breast.
This highlights the poor quality of the scars a little bit better.
Um, next slide.
Um, this is probably helpful.
Um, she, um, they were just really in a bad way, you can see she's got degrees of double bubbles,
and memory of the old crease in the, um, top left picture,
um, and, uh, there was still a degree of deformity in animation,
uh, despite the implants being in a subglandular plane,
so really, you know, everything bad.
So Doctor Cardenas, we're gonna get to start with you.
You're the lucky one here of cases that are very difficult because they have had a lot of
surgery before.
What I suggest to patients to remove the implants, to rest a little bit,
and probably to use fat to inject and to improve the skin quality in the skin tissue and
see how it looks sometimes with fat looks good and patient is happy.
And this is not happy we can try another surgery but with fat and with best cover of the
of all the tissue that is damaged.
So what I would do is remove it, rest, inject fat, and see how it looks,
and then we can go again inside.
She's kind of skinny though.
Any, any other thoughts on this?
Charles, I, I would Like you said, she's skinny, but I would actually have tried to retract fat
in the first session, because once the implant is there,
it's easier to inject the fat, so I would not have lost that opportunity.
I would actually have injected fat before I removed the implant.
Taking as much fat as I can, as long as she's doing high definition lapo sculpturing,
putting fat in, and at the same time, then removing the implants to use that as as a
support. It's, it's easier just, that's my experience.
Would anybody do anything different?
I, I think, I mean we have a very severe, uh, animation deformity on the left side,
so I would try to do the fat and at the same time I will try to take uh do an
explantation and try to reinsert the veal she's actually on top of the muscle now it's on top
of that, so that's just falling from the gland.
It's very interesting so like the window shading so basically um.
I took it, took it to the OR.
I opened up the inframammary increase incisions on both sides.
The left side popped open about 5 centimetres because of the tension on the reverse
abdominoplasty.
Yeah, I, I don't unfortunately I don't have any picture of the in the OR here,
but, um, um, the implants were intact, enormous pockets of course we in last year.
I've got a, if you can go on to the next, um, next slide actually.
But what was very bizarre is that the, the.
It was like uh an empty skin envelope with the breast parenchyma sitting suprolaterally.
So so so um if you go on to the next slide please.
Uh, the next one. The next one.
Uh, yeah, you can just go through that. It's challenging surgery,
of course. So as I said, the left reverse abdominalplasty
sprung open, but of course mote implants very thin capsules.
Uh, bulk of the breast was very bizarre up around here,
um, capsuly to correct the thin mastia, popcorn capsular to try and shrink down the rest of it.
I created some internal perenchimal flaps to medialize the parenchyma.
I used a Gore-Tex purse string around the NACs, um, and did a kind of mini reverse
abdominallast on the left to re-advance these, um, uh,
the tissue, fix the inframammary crease on both sides.
Unfortunately, the only picture I've got was uh uh uh uh from a week ago,
which is taken by my nurses, which you can put up, so,
so far so good, and she knows that second surgery may be on,
on the cards, so, uh, she knows fat grafting and other things might happen.
Yeah, but I mean, just, just correcting the scars alone,
you know, was a big improvement.
You know, her scarring was so complex. So yeah,
I think that'll probably settle out nicely.
You give it more time. Anybody do anything different?
Nice. After the next day, I think we have only 2
minutes. 1 more more.
So, this is a patient from uh Doctor Lazar Cardenas's clinic.
Uh, with a history of 10 years after implant insertion and perolar mastopexy.
Can you explain a little bit about the the patient?
Yeah, well, this, this patient, this patient was, was not,
uh, my patient, and, and she arrived like this, and information that she told me was that she
had a surgery and the, the doctor that did the surgery has,
uh, did a, uh, on a per mastopexy, and, and she had a capsular contractor of the left of the
left breast and what did she want? Well, she wanted to have uh.
Almost the same size, uh, but.
She was a little bit uh uncomfortable of the scars so we she was asking to have
the same the same perolla scar but.
Uh, the, the The asking from of the patient was to have an improvement and to remove the
implant and put a new one.
Good Um, Charles, what would you do?
Are they subglandular? Hm.
Both nipplelorilat complex are also lateralized significantly.
I would, I would, uh, use the capsule. I would remove the upper,
open up, up. I would do the doughnut, remove the capsule,
depending on the thickness of the lower, I would keep that as a hammock.
I would still use the pocket, go in with smooth devices, um,
because she wants to go through the la, so she doesn't want the IMF incision,
correct? No, she doesn't want it Right.
She, she doesn't want it, no, precisely. So, so,
so with that said, I would tell her, I hear you, but I'll give you a small incision,
and uh I would go through the IMF and I would separate those and I would do an a pixie on her
uh medializing it, but I would open up.
I'm not afraid of keeping uh as long as she doesn't have any history with seromas,
etc. this is a pure capsic contraction.
I use it and then I open up and I would mesh it, the capsule and still keep it.
That's what I would do. Patricia, I'd remove the entire capsule.
I think a lot of these capsules are contaminated.
Um, I would do a total capsulectomy, but she has to know a lot of these patients,
somebody said before they like that hard tight breast, they can't feel the implant because of
the capsule, so she needs to know she's gonna have a much softer,
um breast. She can hug people without knocking them.
Out, um, a patient tell me that it's so nice to hug her grandchildren without worrying about
hurting them, uh, we got her capsule out, but, uh, it's interesting though,
a lot of them don't like it when they get rid of the capsule and the implant's mobile,
and I tell them you're probably gonna feel the edge of your implant.
I would consider, depending on how much breast tissue that she had like um um.
Mark said before, if you could feel there's any breast tissue,
I would probably do a pocket change to a subfascial position,
tuck that muscle back down and then um her realist may shrink just from getting rid of the
weight of the implant on it. So let that settle down and see whether she
needs a perureol or mastopexy, but I would do this through an inframammary incision and a big
enough one that's going to sit in her fold that I can see what I'm doing.
And pocket change, you would probably stage the mass.
Uh, it depends, you know, on what how the tissues are after you take the implant out,
um, but a lot of times that that'll shrink when you get this without the pressure from the
implant thelis might shrink down. It all depends on what bothers her.
If she doesn't like alas that big, but I, I will bet that once you take the implant and the
pressure of the implant out with those capsules that that arela will reduce in size,
and then your scar is gonna be a lot better as a secondary procedure.
Uh, Mark, these seem to be, uh, round implants actually high profile or maybe it's due to the
capa contracture that they look so projected. Would you use the again round implants or offer
something different? Well, the first other observation to what we
were just what you were just saying was that those that nipple position is gonna be a lot
lower once that capsular contractors out. That's gonna be a much more and less lateral
and less lateral, there's a very short nipple from every crease.
So I think it's uh it is likely that some form of massopexy is gonna be more important or
as important as the implant choice, whether that stage,
if you can persuade the patient to have that to understand for both you and for her,
her original breast shape, which will be helpful, that's ideal,
but otherwise I think you have to counsel her to allow you to be flexible and that does
include the flexibility of the scarring.
I think trying to do this all keeping around peri aola scars is not something I would like
Paolo said, she does it my way or she can.
That's, that's, that's true. I yeah no no no what I just
wanted to very quickly say that, you know, since um you asked what kind of implants you
would use in this case, um, regardless of what the technique was to me.
If you want to use an anatomical implant in this case,
then you have to use a polyurethane implant because otherwise you will have too high risk
of rotation. If you don't want to use a polyuretha implant,
fine, but then you, you need to use a round implant.
That's my view. Uh, is this a good candidate for a multi
planner. I receive a lot of patients like this.
Let's see how important the ella, the neck is for the beauty of the breast.
Uh, if you look at the breast alone in potential breast,
uh, it's OK. There's no optotic, but with a huge.
That's why we evolved in the multiplying concept to,
to reduce and, and nowadays to don't over resect around around.
That's the concept. I would raise 2 to 3 centimetres,
the IMF, and it's good because she doesn't have a, a.
Uh, if you're in front of the car in the fold, so I would place the use a smaller
implant probably to 20 200 ccs and do a vertical maybe mini
scar as to if.
It's her desire to, sorry, just a very quick comment and suggestion
for everyone doing any of these sorts of cases is take a picture of the patient on table
without the implant. And it's amazing how helpful that is
postoperatively if they're at all disappointed with their results when they see what their
breasts look like, naturally they change their mindset.
Yeah, that's coming before we go you would raise your IMF 2 centimetres,
probably because if you look at the upper pole, it's 3 centimetres or 3 centimetres.
I cannot measure below the inner axillary.
You would put her IMF even higher than it's now.
You would put her IMF even higher up than it's now.
I would raise it looks like she's foreshortened
we just cannot judge without seeing the whole torso and without counting the ribs.
That's what. Looks for me that she got no phone of a purple.
Her purple is way below the inner with a small implant and taking
that into account, I looks for me that raising I I would say I,
I absolutely disagree.
I mean, I, I, looking, she has her arms bent and already looking at that,
her nipple's already high.
And, and I think the solution for her to have a more aesthetic best is to have more volume in
the lower pole and, and, and create a better harmony because right now they're sitting here
and they'll be even higher up. So, but like you said.
We're not seeing her live, but just judging from the photos,
I think she already has a very high riding also secondary to a capsule formation which pushes
up it even more.
So I would actually go the opposite direction, but that's what's beautiful with panel
discussion. Last comment part of you have 3 centimetres
from the Greece to the upper pole. That's why I just.
Pretending imagining that the IMF is low, not sure.
I think we're missing one of the principles that we started this morning about the idea of
breast and how the measurements should be about the 45 and the 55 from the bottom,
so she really needs to reshape the whole breast in order to get it and the.
The only way to do it is taking those implants out, see what does she have,
and then redo it at the same time. Otherwise, Lazaro,
what did you do in this patient?
Well, what I have learned of this patient and a lot of patients is what Paul said and what Mark
said. Sometimes we have to tell patients what we have
to do and not what patient wants to have because if the patient wants to have something
and we can offer a good result with that we have, we have to reject that patient we don't
have to operate that patient in this patient what I did,
can we, can we go further to the other, the other slide.
We, we change the. You use round implants.
Excuse me. These were round implants with new implants in
round ones and the same, the same size and the whole breast is sitting further down
when you, when you look at the positioning, the whole IMF is further down because she had a
total displacement, especially on her left side medialized cranially,
and I think that creates a much better balance on her torso.
And it looks much less projected also.
OK, very nice. We we've been given a green light for one case.
Oh my,
I'll give you I'll give you an advice. I think you should raise the rest.
I would agree on that one.
That I would agree.
Uh, we have a 22 year old patient with previous surgery necrosis of the right neck.
The right neck is too high, and he had the implant extrusion that was previously
subglandular on the last surgery, and, and that's it.
Yeah, she, she definitely could not wear a bathing suit very well,
that's for sure. Um, so anyway, I think what would you do
implants now, this is just a reduction. It's complications from a breast reduction.
Yeah, OK, would anybody like to start first? I mean,
since it's not an implant case, reduction case like to,
I don't think that I would like to start with this patient,
but the thing is this patient has no implants.
She had a very severe sequela after intent of the breast reduction.
And so, uh, the only thing to go with these patients is try to do it's,
it's very hard to see where the informammary fold is uh,
uh, it's gotta be low, but you never know where, but definitely,
uh, the only way to to go with these patients is we need the the all the volume in the upper
part. Uh, in order to reduce what we have hanging
there, so definitely we will need a mesh in order to control the position of the flaps,
and, uh, another thing that we need with these patients is to see how the vascularity of the
gland is. So we probably will do an an angiogram and.
In order to see how the vascularity of the of the gland is and see if I can use an inferior
pedicle gland in order to put it on the centre of the flap and then try to raise the
IMF in order to get more volume on the upper pole of the breast and then close it with that
inverted teeth. Yeah, I almost wonder if doing any sort of a
pedicle type transposition is even worth it since the nipples already died and healed.
I mean, this seems like a case where wedge excision might be the,
the smartest and safest. That's the horizontal,
yeah, because you've probably, I mean this is probably a Mallucci 595.
So I mean this is really, so I, you know, I.
I don't know. Would anybody do anything differently?
Just, uh, you know, Charles, it seems, it seems that the nrala complex are in right position
about the distance. It seems, I don't know you have the distance,
uh, because if you have the distance is correct, what we have to do is only to.
Work on the lower part of the plan and to and to lift it uh and and don't don't move the the
nipple so we need to see how is the distance and the other,
the other nipple where you don't have the profile view to see how is it probably with
with uh tattoo or something like that we, it can work.
I mean, I, I obviously it all comes down to what the patient wants,
but I agree, you know, like it, it seems like, you know,
you could actually amputate that lower part of the breast and maybe even put a small implant
without doing. a raise of the nipples because they seem to be
quite OK. Yeah, you don't want the nipples any higher.
No, that's what I'm saying. Yeah. I, I think what one needs to understand,
if one amputates the left breast, that's heavier, the real complex will come up higher
because there's weight in that. So I would not manipulate.
However, I would probably after 3 surgeries, be careful putting an implant.
I would go for fat. Absolutely. I would stay away from.
Uh, and just being cautious the way I am. I, I would,
so do the horizontal, very simple amputated and fat, which would probably also soften her
breast in general.
That's it's safe.
Any audience questions? Would you guys do anything?
Anybody have any uh comments?
But let's see what let's see.
Oh, it looks nice. In the video, Can you run the video,
please? Right the oh there we go. Mhm.
I want to show the Oscar that we performed in her preview of the scar.
And if I may I ask, how many of you perform Eskarmastex for women as a rent?
And I'll keep with Doctor Rankin's question. Why?
Uh, we performed the Oscar multipla Oscar Masopexy.
We're the IMF 2 centimetres for her, but we, we just reason because that's the place where the
muscle is we use this the muscular, uh, breast implant.
I like whenever we have previous surgeries, uh, I rather resect tissue and use an implant
instead of cutting the parma doesn't know when where the vascularity and with the risk of,
uh, fat crosis.
And whenever we perform the internal muscleexy that's so in the parenchymature the muscle,
we always raise the neck and considering that parenchyma has been completely undermining from
the muscle, I just lowered the neck, the right neck a little bit.
I try to lower it so.
Uh, releasing the par from the muscle and sewing it allows us to middleize,
generally, or lower the neck. What's really difficult to,
to deal only with the skin.
This is a like 3 days postop. I think we have a,
a. Well, that, that's a wonderful result, and I
think that, uh, you know, we're pretty much out of time,
so I really, I think we got to go out a long, long up another follow up have another
10 there we go. Oh, that's 6 months post so the neck has
survived. We got smitted for the, the surgery.
Now she's scheduled for a now we're going to do a reverse of the we've seen,
I think on, uh, Pacification.
The hugest scar. So whenever we raise the IMF,
we'll never combine a reverse of abdominal pressure to not having over retention on the
suture. So we just fix the new MF and now one year
later we may do a reverse abdominal places and for her we'll we'll perform it just to to have
uh the the beautiful shape of the the previous car.
Very nice, very nice, very nice.
I'd like to thank the panel.