Onto the next sessions.
Now we're gonna have planning and choosing anatomical implant and once again we have two
great speaker and we have Mark Pacio from the UK and Dominic Bagoa.
So to be honest, who wants to start first?
Doctor Pagover. Thank you.
Good morning. There is a 4th article in 2017 saying
that more data had been produced in the last two years than in all previous history of the
human race.
That's insane.
But could you believe me if I told you that less than 0.5% of this data
is ever used?
That's crazy, right?
So I've been gathering a lot of data for many years.
I, uh, did this with a team of 9 plastic surgeons in Madrid founded by Doctor Martin
deerro, and we've analysed long term follow up up to 21 years of
more than 1600 implants.
But when I try to share it, it is, uh, it is too much.
There are too many data here and I want you to be able to use that in your favour.
It has been very useful for me in my practise, so I started thinking how can I bring this to
you in a way that is compelling and something that you may remember and you see it in your
own practise? So I remember this YouTube videos were famous
people answer the most commonly asked question about them on um on Google have you seen them?
So I thought we can do that with the most frequently asked questions by our patients,
but my patients.
So CPG is our famous guy. Let's answer some questions.
Can you guess what is the most frequently asked question?
For me it was, I'm my influence for life.
I, I'm gonna have to change them, which is a really logical question,
right? And I always tell them the same thing.
Any implant, whatever you're using, it's a device and you can't expect the device to last
forever. But you know, I can tell you something.
After and I say this in a positive sentence because it's supposed to be to have more impact
when communicating. After 21 years.
More than 90% of the patients are still with the implants,
and let me tell you more.
The main reason for exchange or um removal is aesthetic.
Did you decide to like you are doing right now?
This is a very powerful message to deliver.
Can you guess what's the 2nd most frequent reason for removal?
It's implant rupture.
In our case, the capital mayor dropped her rate at 21 years was
5.1%, which is pretty good.
Um, for breast augmentation, I'm sorry, it was just 3%,
and this is not clinical. 85% of these patients have a pretty recent
imaging test addressing implants integrity. That's not only clinical.
The second question I asked, I, I get asked a lot, it's about capsular contractor.
And I was in Australia some months ago and I was shocked because one of the surgeons there
told me, I tell my patients 15% risk of capsule contractor and blowed my mind
like we could have a problem if we had that numbers, right?
So when we did our numbers, of course you need to do your numbers,
but it was pretty nice. We got a capsular contractor rate of 21 years
in a cumulative incidence Kaplan me 1.7.
And let me tell you something at that point we're talking 2001 to 2011.
There was no Adam 14 plan, uh, point. There was no antibiotic.
We just did careful precise dissection, betadine and change of gloves.
We studied all kinds of risk factors that could impact on capsular contractor,
and we only found two significances.
The first one, having had a previous capsular contractor, if you had a previous capsular
contractor, at 10% of the patients are gonna have another 1,
10% versus 1.3% in primary surgery.
And uh Using an a approach increased 12 times the risk of capsular
contractor versus IMF.
Another frequently asked question is the things with breast cancer.
Would, would I be more risk of breast cancer, uh, problems with breast cancer screening,
and the short answer, of course, and breast screening is of course no.
And in breast cancer we analysed post implant breast cancer diagnosis and I was kind of
shocked by the results. I'm not jumping into any conclusion here
because we need to be very careful, but you know these publications about immune
surveillance and breast cancer temperature.
And we found that our post- implant breast cancer diagnosis was pretty low considering the
uh average population estimation in average um woman.
The 4th question, it's about breastfeed. Will I be able to breastfeed?
It seems like that you will probably be able to even in cases with tuberous breast extensive
dissection and falling technique when asked, and I also say this in a positive way to the
patient because this is important.
More than 8 98% of the women that tried to breastfeed after having an implant were able to.
And that is according to US statistics, this is pretty average.
So yes, they can breastfeed after breast surgery with implants.
And of course the 5th 1, uh, the big issue, uh, I get many patients because I use a lot of
anatomical devices and they come to me and they say, hey,
I, I like the anatomical shape, but I've been told that they can rotate.
And of course they can rotate, but I tell them.
Um, we've analysed more than 60, 1600 implants and
only 31 had any kind of rotation and only 11 required reinvention
to solve that rotation.
This is 0.5% of the total.
And it was more frequent as is obvious in breast reconstruction and revision augmentation.
And this brings me to the second part of my talk which is how I perform my pocket and do my
surgery to try to prevent this rotation to happen.
And I would like you to introduce you to this guy.
Does anyone know who he is?
This guy, uh, it's, it is estimated that he has saved more than a million lives,
you believe it? This guy is Niels Bolling.
He was a Volvo engineer and back in the 50s, he designed the three point seat belt that we use
nowadays and versus the lab belt that it was used at that time,
this um this uh belt that crisscrosses the body, it is supposed to decrease uh injuries and
death by 50 to 60%, which is amazing, right?
So I, I like, I used to use a dual plane when using anatomically and I like to think about my
vector is major muscle as my implant seat belt and that that's how I do it.
Um, I look for the lateral border of the pectoris my muscle,
never lateral to it, release the inferior part, and in the external part,
I do a transition. I cut almost completely the lower part.
I just leave a small strip of fascial tissue and do a long transition until the 4th
intercostal space.
So that this area in white does not have a strong contraction ability,
but there's a strip holding my implant in place.
It gives me some stabilisation.
Then look for the 4th intercostal space um space artery and cauterise it because sometimes
there is insertions there and uh there is a risk of hematoma afterwards if you forget it
and you need a space in the medial part so the implant don't go lateral.
It doesn't go laterral.
I try to avoid slateral release from the muscle and the gland,
and uh I respect, try to respect as much as possible the lateral facial condensation as
described by Lagood.
What is the aim of all of that in my mind this helps me to get a maximum pectoralis major
contraction as horizontal as as possible and um above the 8 point,
the most projected part of the implant so that I can prevent rotation and that and this way I
have my own implantsal with my three points of stabilisation in the middle part,
in the lateral part and the strip of muscle that crisscrosses the implant.
Here's a very quick quick video I'm doing that. I'm just releasing the inferior insertions.
I always check tissue thickness with my non dominant hand and in the medial part I leave a
small strip of tissue and then cut the muscle and and do a transition until I
get to the artery there.
You see here I'm leaving some muscle there not complete because if you do a complete release
you're gonna have strong dynamics and cauterise the artery.
And then I don't go uh after the lateral facial condensation and if I need with the
cipher or the implant, if I need more space in the later part,
which I do, is to do some slight cuts in in the lateral pole like
small cuts cut in the fascia so that I can get some expansion and make room for my implant
without doing my pocket wider at the horassic Wall.
And combining this tight pocket with uh this relative position between the muscle and the
implant, you can get also really nice dynamic even though you're using a dual plane.
This, for example, a tuber's breast, more extensive diss,
more aggressive surgery. She's a slight dynamic in the left side but
pretty acceptable with nice result and nice expansion and even in breast reconstruction,
you can get that too.
And um if I failed miserably in getting you to remember any of these numbers,
I got you. I would like to at least take two key messages
from my talk, and to that let me share one last story that I love.
Maybe you have used uh you have heard about it.
In World War II, the Allies tried to reduce the number of bombers get shot down by the enemy so
that they can produce casualties.
So they thought about analysing where these bombers were shot the most so that they can
reinforce those part, those those parts and.
Uh, improve their results, right? And they got something like that.
And the result was obvious, right? We need to reinforce those parts and our
bombers will be will be safer, but Abraham Wall, a statistician working in defence,
saw it differently, really differently, and he thought it is likely that the bombers are shot
at every part, but the ones that are shot in the engines,
the front part, the tail, they are not coming back, so we are not analysing them.
So what do I mean by that? First, we need to have our own data because
sometimes perceptions are deceiving and we need to be careful with with our conclusions.
Which brings me to my second point, which is Um, if you are only using,
because I'm seeing this a lot, especially in younger surgeons,
if you're using just CPG in your most difficult cases, tuber's breast,
uh, really complicated test wall deformities, your surgery is gonna be more complicated.
Your pocket it's gonna be less precise and that's completely OK.
Like you can use whatever you want, but if I'm to use something new I could choose the most
perfect. Indication for that implant so that the can so
so that I can start evaluating my technique with that implant because there there needs to
be a match, right? And if any of this is useful for you and that
that was a disaster, at least I hope you get a little bit inspired to get your own numbers if
you haven't done so and bring them to us and we can all together make a surgeries safer for our
patients.
So thank you for a fantastic talk, Sara. um.
I think the data is incredible and and actually that study is probably the most powerful um
study with contemporary data for uh anatomical implants, so that publication is going to be a
must read once it's once it's out there.
Um, and we, we've heard a lot about arguments for different types of implants,
and I think, uh, the point's been very well made, um,
earlier about using the implant, uh, getting to know an implant,
you feeling comfortable with it and getting the best results for your patients.
Um, and my talk is going to be, of course, about anatomical implants,
which, as Patrick.
Uh, outed me earlier. I've swung my pendulum back towards having,
uh, been a very early adopter of smooth implants in the UK and,
uh, actually being lambasted when I presented at BARP's in 2015 or so of my experience with
my 1st 50 smooth implants. I, um, I, I, I got a lot of flack for it,
so it's interesting how times do change, um, and I think.
This is one of the problems with anatomical implants for those who aren't regularly using
them is people are quite scared of using them, and they're quite scared because there are more
dimensions and more uh uh factors perhaps to think about or certainly it can feel quite
scary to think about planning and using because this is not as simple.
But it doesn't have to be difficult.
It doesn't have to be as complicated as this when we're seeing publications of how to plan
uh positioning of implants.
It doesn't have to be as complicated as this, which is one of my patients.
um, it can be as simple as this, much like we heard from Pat earlier that you don't need to
overcomplicate some things. So.
I guess before we come on to my thoughts about planning for anatomic implants,
um, we've already heard some discussions about why we might use them,
um, and they don't only have to be used with difficult cases,
but they are particularly useful for difficult cases.
And one of the key things about an anatomical implant is of course you,
you can vary the height and width, so whether you're using a tall height or short height or
somewhere in between that.
Allows you to tailor that implant much more with much more precise predictability.
So that height and width variation I think is absolutely critical.
And then the point of maximal projection is offset from the centre,
so it's below the centre and the midpoint of the implant,
and that can allow a whole host of advantages that can be exploited,
particularly as that point is normally going to end up just below the nipple,
which is going to be very useful for reshaping the breast.
And of course by definition, anatomical implants tend to be more cohesive,
which, as Pat said earlier, does mean they're a little firmer.
They're still soft, but they're a little firmer. If you put them next to a smooth implant,
they will be, of course, firmer, but they do allow you the ability to shape the breast to
impart more of a shape change to the breast with more control and more predictability.
So, as I said, the um planning decisions, they don't need to be difficult.
Um, the, the base width is something that's fundamental in any breast augmentation,
and one point that Paolo was uh alluded to yesterday and we've heard before,
and I think it's absolutely crucial and is often under,
um, played is the breast height, and I think uh recognising the height of the breast and um
the. Establishment of the breast crease as Patrick
talked about earlier, is really crucial as well, because those IMF decisions are absolutely
fundamental, and of course we need to think about the position of the uh of the uh Narriola
complex. So I think that the, the first take home
message is the point of maximal projection needs to be,
uh, it needs to end up below the nipple.
And you can see a variety of patients here, and these have been marked purely for really
illustrative purposes. I hope this laser works,
but the, as you can see, uh, as per Hayden described, uh.
Looking at the point of the nipple position with arms by their sides and then with arms
raised above the head as a guide to where that future nipple position might end up is quite a
useful point to mark and it can help with some of the decisions about the crease,
but not only the only decisions about the crease.
Implant height is key, and I think understanding the height of the breast is
really important, uh, because once you've established a height,
planning then becomes effectively like planning with a round implants,
that's once that's taken out of the equation.
Um, but you need to look at that height because personally I don't want a breast,
uh, certainly a breast implant sitting above the natural borders of the breast.
I don't want, uh, an implant starting at the clavicle.
Personally, I think that looks unnatural and it's not something that patients who seek me,
uh, desire. Um, and there are a whole variety of anatomic
landmarks and judgement we can use to make that, whether it's this dry in,
uh, breasts and that's usually a very accurate mark, uh,
the extremely fat pad, upward displacement, and possibly the second,
um, uh, the second. Rib. I don't know how well this projects,
probably not very well, but mostly if you're looking for those anatomical features,
you will find in the patient and you can mark them on the patient,
and that can give you your height. And don't be afraid to put a couple of dots on
while you're examining them for the first time just to help with your measurements.
The other key thing, and I certainly when you're starting out doing breast augmentation,
is the IMF decisions and whether or not to lower it,
and the paper I would absolutely recommend everyone reads is one reference at the bottom,
which is a Craig Late paper which effectively summarised what is has been intuitive to those
experiencing breast augmentation for many, many years.
The fundamental message is if the crease is well established,
do not lower it. It's like Patrick was talking about earlier,
you will get a double bubble or you'll be lucky to get away with not getting one.
Um, and the key thing, as I allude to in that paper, is if you ask a patient to put their
hands behind their head and they've still got a marked crease visible,
that is a, a, a, a, a very high risk predictor of a double bubble were you to lower the crease.
So therefore, in patients such as the one in the picture,
who's got a very established crease, she's got a difficult breast shape cos she's got a very
short height breast. One is bound by the breast crease at the bottom
and the breast height at the top.
And I personally would find that very difficult to achieve a predictable natural result in her
using a round implant because her anatomy dictates the implant that I might choose.
Um, There we can see those there. So once we've determined the implant height,
once you've marked those, uh, you have to decide whether or not um if there's a softer
crease, you might have a bit more flexibility and the ability to lower it.
If it is a less marked crease, such as the, the flat breasts that Paolo referred to earlier in
some way we've seen before, or breasts in which the um the crease is effaced on arm rays,
then you have a little bit more flexibility.
So an F or F2 fold, as Craig Lake's paper describes, they,
they can be lowered.
Um, what height? Well, you've got to determine that according to
the breast. Uh, short height implants, I think are
fantastic for those difficult breasts. A tall height implant can be useful for either
a low footprint breast or a breast with a naturally tall height.
Um, otherwise, the, the medium height breasts, if you're starting out,
are very safe, usually to go for irrespective of the manufacturer.
So If you're thinking about the breast in which a uh an anatomical implant
would be particularly useful, well, they're ones in which you can exploit the variation of
the um the height and width, so they could be in those with mild ptosis,
significant breast aplasia, and requirement to force the shape of the breast,
such as typically tuberous breasts.
I'll show you a few examples.
Um, here we can see that patient we saw earlier, you can see with very short height breasts.
um, I've um just lowered the er fold on the left of fraction because I thought that might
just mask a little bit more of the asymmetry, and I think she's got a reasonable result with
a short height implant, a result that I don't think I could have replicated with a smooth
round because of the unpredictability, and you sort of,
as someone who's used quite a number of smooth implants.
You, you sort of have to have, uh, sort of the faith that the lower pole will expand,
and there can be a degree of unpredictability uh in that,
but as Pat said, the results on the table will not look like the result in 3 to 6 months' time.
So there's a short height brace uh breast with an F3 crease as described by Craig Lane.
Um, again, a similar sort of breast, uh, one in which if you looked at the post-ops only,
you might assume she had a a round implant in, but actually the shape of the breast
postoperatively is irrespective or unrelated in a way to what the implant is.
It's about getting the right implant for the right breasts beforehand to achieve a
particular result. And then for the flat breasts,
there's significant hyperplasia, I think the ability of that anatomical implant to impart a
uh a good shape is very useful and can be exploited very well,
and that these patients are often quite difficult cos their tissues are very thin,
very delicate and despite.
Significant reinforcement of the inframammary crease with the smooth implant,
which I've, I've used er er in different patients.
The predictability of that implant staying where you want it is less than with an
anatomical implant, hence my recommendation in these patients that they have an anatomical
implant. There was a patient last year who persuaded me
because of her worries. About to use a smooth implant and inevitably
she got mal position issues and she holds blames me squarely for
those problems. You're constantly learning throughout one's
career and sticking to your guns and being prepared to lose any patient is far better than
having your arm twisted in many situations.
Um, and then we've got, uh, a more extreme, you've got a,
a significant breast aplasia and pectus, someone who's had a differential anatomical
implants and, uh, uh, an internal mesh.
Um, I, I think again, I don't think I could have got such a,
a natural nice result with an anatomical limer without an anatomical implant.
And we saw some fantastic transgender patients from uh Pat yesterday.
Uh, but again, I feel I can get more of a predictable result with an anatomic implant,
particularly forcing that tight lower pole in that masculine chest to start with,
uh, to achieve as aesthetic result as possible.
And then of course tuberous breasts where you really want who who effectively will have an
F2B or an F3 crease, where you really want to force the shape of the breast,
I think the anatomical implants are, they really come into their own.
So Patrick, er, stole my thunder because uh my um my practise has changed and perhaps if I
just broadly put it into the pre and post pandemic uh time uh time slots,
but I, I was, I did go through a big phase of using lots of smooth implants,
um, and I'm using more anatomical.
Uh, why, uh, maybe a change in my patient demographic, certainly a change in me,
um, I'm doing more and more. Complex cases I seem to attract people with
different breast shapes, but also do a lot of secondary and revision surgery where again I
think the anatomy implants give me more predictability, particularly once I've uh taken
the capsule out of the equation or needed to, um, and marketing reputation,
I don't know. It it it's just become something that has
certainly given me more control a feeling of more control in my practise.
So, final slide, um, anatomical implants are not hard to use.
They seem scary when you're uh in the that early learning curve,
but just like anything, you get comfortable with them and they're absolutely fine.
Um, they do require, as we've heard, uh, from Sara just before,
precise surgery, um, rates of mal rotation, I've had one that I know of clinically in the
last 12 years or so, who of course was another medical colleague,
um, but, uh.
Uh, and, and in fact that she didn't require reoperation, she managed to relocate it herself
and her breasts look, don't look bad enough to warrant going back in again,
so we've agreed just to watch and wait.
Um, I think the properties of the shape of the anatomical implant mean they're incredibly
useful, can be incredibly useful.
Um, if there's only one message that you take from this talk.
It's don't lower the F3 crease.
Don't lower that well-defined crease because you will find yourself in a whole heap of
bother that's hard to backtrack from.
Thank you very much. I know
we've got 5 or 10 minutes for questions. I don't know if anyone has any questions.
Um, sorry, do you want to come up here?
Any thoughts, comments or questions?
Patrick, have you got a microphone?
Oh, comment about not lowering the crease, absolutely agree,
but that's also going to limit the implant size you can have in that patient because when
you're not lowering the crease, all you're doing is loading the upper pole of the breast,
um, if, if, if you're oversizing the implant. So yeah,
but I think your aphorism that I use in a number of consultations is not what you want,
it's what you can have, right, comes into its own there.
Thank you for that. Any other thoughts?
Just by show of hands, how many people tend to use predominantly round implants in their
aesthetic practise here?
And how many is anatomical?
It's about fifty-fifty, probably, this broadly.
Uh, and just one further question on that front, how many of those who use round might consider
using more anatomical from the data and the, and the thoughts they've had from the last
couple of days? That's good, you That's better than nothing.
Um, any thoughts, any questions from anyone else?
Right, I think just the final point maybe to make is kind of what Patrick uh said about risk
and perception of risk, and I think my one of my um messages I always often like to give
is you we shouldn't be making an implant decision when it's with respect to risk on a
single risk factor, because there are multiple risk factors in any implant surgery in any
surgery, whether it's caps the contracture, rupture, malposition,
ALCL all sorts of things.
You're purely making your decision on one factor, you're neglecting the bigger picture
and I think that risk of the overall risk to the patient over their lifetime of re-operation
and other factors really has to be taken into account, certainly that's uh that's my view.
I think we'll end the session there, thanks.