The session is supported by Huerigold. There is anyone that will come.
To moderate, no, I am the speaker actually.
Then the is the right advice for the for the right case my personal experience and we will
talk about the pre back no IDM no measures.
By disclosure, uh, all the same that we, we know that we have a general philosophy that
is DTI versus two stage and pre-pe versus retrope.
My philosophy is DTI and pre-Pack every time that I can.
Why? For many reasons actually.
First of all, in my hands, no comparison talking about results much better with DTI.
Then you don't have any nipal complex dislocation because when the,
when you put a tissue expander inside that the the skin lies down and goes laterally and you
can have uh dislocation that is impossible to fix and you have to remove it and put it in the
right position then uh no problem uh related to the to this issue.
It's quite easy to understand psychological advantages.
Everything is fixed in one stage.
You do cancer removal, reconstruction everything's not better than this,
and it's less expensive anyway because you do just one procedure,
then one admission, one anaesthesia, one I think that's much,
much better also is we, we did a study in my department also if we use an ADM.
In DTI is less expensive anyway, why prepack?
For because it's more physiological, there is no one emission animation is a side effects,
but the patient hates.
The the animation because it's it's so uh.
So ugly actually much more natural results and then less pain,
less discomfort like a stone that change and becomes harder when the,
the, the weather changes this this really deep every everyone knows all the problems related
to the retropector position.
Then when I changed my mind.
When in now it's 10 years when um Angelina Jolie.
Uh, decided to, to, to say to everyone that she did a,
um, specific, uh, test is to BRCA and she was BRCA positive with a
very important, uh, family history about uh breast cancer that she did a prophylactic
mastectomy that increases a lot the number of patients that comes for prophylactic mastectomy.
But the problem is that the patient that is disease free.
Don't consider at all any possible complication, any small imperfection,
any aesthetic defects, because they just think that they removed the glad they put an implant
inside. It's like an aesthetic procedure.
It's true, but it's not so easy and if we do really a prophylactic mastectomy,
we have all the problems that we can have if we do a cancer removal because we do exactly the
same thing and then same possibility to have problems well.
At that time, the possibility was to do a ravioli technique.
Was an Italian device and uh ADMor sign derived.
But unfortunately I have a quite good experience with
ADM, uh, from the October 2010 to December 19 uh we did
in my department almost 500. We use almost 500 ADM,
and uh we use a lot of them.
We start with Veritas, move to stratus and Tutome mesh simen,
and the end X shape.
It's very important. The first and the last one are the same kind of
idea bovine pericardium.
And with the first one I had an unbelievable numbers of problems and I
didn't have anyone with lust.
How is possible? The actually when I started using ADM and I was
so enthusiastic, I had so huge percentage of complication,
around 45%.
And then I stopped to use it.
I start to to study.
Why I had so huge number of complications and then I reduced the indication but anyway we
dropped down to 18, but 12 were made by seroma.
When I say seroma, I mean that I was obliged to leave for more than 3 weeks the drains.
I consider until 21 days acceptable after 3 weeks is unacceptable.
Why? Because we have a lot of problems.
Patients that must go back and forth for their home is really uncomfortable.
Then, what about antibiotic therapy? You have to stop it.
After 3 weeks, it's a long time, or are you continuing.
Then You remove the drains, but the seroma goes again and and you
have you're obliged to pinch from outside and remove the seroma how many times you can do in
a safe way without bringing the infection inside that a lot,
a lot of problems. That's why and the aroma,
why you have the seroma, I think it's we don't have any clinical evidence,
but. Logically you have 3 possibility, 3 main
factors. The first one is the uh uh derivation,
but I, when I talked with the American friends that can use the alloderm,
we cannot use the human derived.
They told me that they don't have 2% more or less 12% is nothing
and then probably the derivation is very important.
The second one for sure is the the chemical treatment just to became an ADM,
um. The reason because Veritas and uh Exa shape did
to make completely different uh results probably for chemical treatment the same
derivation but uh different chemical treatment.
The 3rd 1 is the extension like a burn.
You need to be integrated, then it means that uh if you have a new if I
use just as link as ADM. I use just a link in in lower pole,
it means 18 centimetres timestamp.
And then it's 180 square centimetres.
If you use the ravioli technique, you have 12 times 30,
it means 600.
Now I don't want to to say that you will have 3 times more complication,
but you will increase for sure because one of the factors is how much device I have to
integrate then inflammatory process is bigger for sure.
Then it's why I said no thanks I don't like to use the ravioli to go because do you know why I,
I have, I am what the the companies call early adapter if you come to me and to.
Uh, as a company and to, to give me the option to use you,
you call me and you explain me your new device and is logically everything is logical.
I will start to use tomorrow but if you say something that is not logical for me,
I will never use all life long.
Then the ravioli for me was not logical and uh especially with so huge amount of device
then. I, I thought, why don't use polyuretine?
Unfortunately you don't have it, but in Europe we have it polluted and
If, if you go and compare the technique and polluter, you will see talking about thickness.
The ADM is 0.6 millimetre and it's it's hard.
The pollutant is 1.4 millimetre and it's soft, it's a sponge.
Talking about rotation, you need to fix the ADM on chest wall.
You don't need to fix pollutant that's stuck on chest wall and then it's fantastic talking
about the, the, uh, capsular contraction rate.
Everyone says that we have less capsa contraction rate using ADM.
It's true, but we don't have any clinical evidence about that.
We know that using pollution, you will live for sure, and there is evidence less capsa
contraction rate. Then talking about complication I said before,
and you don't have any extra cost then many, many advantages and then I started to use
polyureygen. And I define, uh, as you, um, a show before,
I described this technique as 4P brand method, 4 pieces for pollutant and prepectoral
positioning. I published the after one year.
I started in December 2016 and 17, sorry, I, I published the first paper with
the first, uh, results, then the second one.
And now I'm publishing the last one because we crossed 1000 patients and we uh
uh these are the numbers you will see this unbelievable bilateral cases we don't push but
uh the people, you know, our job are part of the social media our job still remain a word
of mouth job. It means people uh people satisfied the talks
and speaks with the other one and.
Other other patients come to us and we have a lot of bilateral case because we
collect a lot of prophylactic mastectomy and then it's bilateral.
Uh, we put drains in 100% of our cases. The average time in which we keep the drains is,
uh, almost 2 weeks. We do antibiotic therapy for a long time that,
uh, until the, the drains are removal, and there is no contraindication for radiotherapy
patient. What I want to say with this last, um,
quote, I.
When we do a two stage breast reconstruction, uh, and we did,
we, we knew that the patient uh will be obliged to undergo a radiotherapy treatment,
uh, we try to do immediately the subs a very quick inflation,
then we, we do the substitution before to have the radiotherapy with,
with definitely implant.
Now we put 3 definite implant. Then there is no reason if the sentinel node is
positive and we do accelerate this section.
Uh, probably the patient will have 3 nodes positive and she will be obliged.
Well, no problem, definitely hint that we don't change our strategy.
Well, talking about complication, I think it's important.
2% of major, I mean one total failure, we had 26 infections,
we saved 25% according to a protocol that we changed a little bit,
uh, that is used in Nottingham by Steve Malley.
And Doug McMillan, yeah, we just changed a little bit,
but it, it, I have no time to explain. But if you want in the questions,
we, we can talk about it.
4% of medium then it means flap surgical revision we are obliged to go back in UR and
try to adjust something.
80%, 8%, sorry, of mini minor um complications talking about scar revision,
uh, minimal tissue suffering, partial nipple complex suffering,
and One chapter is dedicated to lipofilling. If I'm
obliged to do the lipofiing within the 1st 12 months, it is my fault.
It means that I did a wrong indication. I consider it a complication because the
patient is obliged. We say to all our patients in implant-based
best action in the future you will, you, you need to have some lipofilin because you will
have some atrophy of the tissue.
The, the coverage will not be so nice and then.
Uh, you, you need to have lied if you are obliged to do within the 1st 12 months,
I consider it the sort of wrong indication. That's the,
the paper that we published about the infection, uh, we treat the infection and a couple of
cases with, uh, 6 months on long term 2 years post-op frontal view and lateral
view all all our incision is in inflammammary fold.
We do just the approach as in inflammammary fold.
And uh 2 years post op the this the scar is completely disappeared.
That's it. Uh, it is really aesthetic procedure and uh no
one, no animation, uh, just if the patient bend down, you can start to see after 2 years,
uh, blood in wrinkling that uh we, we will treat.
The results are so beautiful that you can think that OK,
you just do something like breast segmentation.
This is a digital mammograms in which you can see that there is no residual gara tissue that
is safe from an archaeological point of view.
Uh, it's a nomogenesis section, all same thickness just close to the to the scars we
have a little bit more, but anyway, um, there's just the implant inside and she is the owner of
these digital mammograms after 9 months pre-imposed off and large review and.
That's it. And the uh.
She was, she wears the same belt after 2 years actually.
Luckily in the opposite position, yeah, and she has some like this because it should be exactly
the same, same pants, same belt.
Just you can see, the skin is a little bit different, yeah,
anyway, wonderful results. Then the question is why if you are happy with
polluting you have to change you have to do something different.
Because the reality is they are not so happy.
Completely happy and uh second reason because uh there is someone that cannot use polyurgen
and uh.
There is someone that don't want to use pollutant because it's a tricky implant.
Uh, there are a lot of legends around the, the pollutant.
Uh, if it's difficult to remove it. The, the capsule is,
is very, uh, very hard to remove. It's, uh,
more or less legends more than, than, than true anyway, but especially because I want to expand
my indication because as I said before, if you try the pack,
you never go back and then it means that I want to stay on pre-pack position.
According to the paper that Nicola um mentioned before, uh,
wonderful paper, I think that's type 3, the 2 centimetres is really too much.
If you wait for 2 centimetres, probably you will go pre-packing for a very small amount of
women. Then I decrease to 1 centimetre.
And um I should before uh the uh uh my, my decision is according to
these characteristics to go on on pre-pack and with pollution,
but I can go in in retro pack in the opposite direction but there is
something in the middle, something in the middle is you have poor tissue quality,
not exactly bad it's difficult to explain. But it's just according to your clinical
experience that you have something that is 1 centimetre more or less uh and uh
age just in the middle then in this case in which probably is a little bit too risky to go
pre pack with pollutant because pollutant has a very great addition with tissue and then it's
possible to have to have wrinkling. I go with microt texture implant and.
Uh, the, um, extra shape to cover just the frontal portion.
Sorry, I don't know, uh, it started, OK, and it's what,
uh, what I do I just mark the.
The central line and then the inframammary 4.
And I asked the patient to put the hands on the flank just to to check the the
pockets how how um the wid of the pockets then I fix and I mark the
lateral side and and the medial side then where the where the tissue,
the, the glandular tissue ends because I, I want to have a smooth transition between the uh
the upper portion and and and the chest wall. I don't want to have any steps.
Then I, I.
I define everything. I take the central the central line because I
go 2 centimetres away from the central line just to save the pedicle for the nippalobela
complex and 7 centimetres long in infraammary fold.
That in a case like this one which I have a small doses,
I don't touch at all.
That's it. Then 7 centimetres long.
It's a little bit laterally. I can go if the sentinel node is positive I can
do the axillary dissection from the same incision.
I, I'm not obliged to do different incision for the axilla.
I just take the, the small one for the sentinel node.
Then I use electrocautery for the lower plane.
And according to my uh to my marking, I, I go and, and,
uh, and then I help myself with, uh, longer tape more than with,
uh, the, um, light retractor, uh, to go up in the um in.
In the upper quadrants, then I do the uh when I'm happy about the dissection,
I go and prepare the uh the the upper plane by scissors.
I don't use electrocautery because I don't want to to do any thermal injury.
Uh, to the, um, upper tissue, I want to avoid, uh, everything that can,
can give me, uh, some problem in terms of seroma or in terms of,
um, uh, possible burns to the, to the dermis that can expose my implant.
Then I go up, I go and look for the right lane.
The 1st 2 centimetres are under direct vision. Then I use scissors like for a a face lift.
Actually my left hand is on the on the scissors, but uh if I if I need to to take a video,
it's impossible if I put the ends, you don't see the the scissors.
Uh, the tip is, uh, go go down, uh, the, the tip of the scissors and then under the
cushion I remove the bridge between upper plane and lower plane.
That's I I removed the uh.
The glandular tissue in this case, the the the the cancer was on the opposite side.
But for me I am right handed and for me it's much better to the video on the on the right
breast and I put some uh referral point for the um
for the pathologist and and then I'll I'll go and uh and use the
um. My Device actually and I, I'll I'll show
you. Well, I put a sizer inside actually.
I use all the sizes when I do, uh, breast reconstruction.
I use all the sizers because, um, I, I want to check if everything according to the
measurement that I did before, uh, it works perfectly and,
uh, that's the, the result with scisors then I use the,
the Xsche uh, you will see in the in the in the box there is a tray.
And uh it's very very easy you have just to fix um to to put a a
sutures just to um to to.
To close on the back, you have the is a meshed and is a pre-meshed.
And the P, it means that you have to put the the implants,
the prosthesis just face down, uh, because it's a double layer and it's smooth inside but it's,
uh, it's rough outside and then can grip on subcutaneous tissue.
I just put some uh some biryl, uh, along the, the small holes and then when I finish up
I just uh reiterate the ADM with a couple of um.
10 cc of water is more than enough in 22 minutes is completely.
It's completely reiterated well that time I, I put the implant inside.
And I go and close After one or two cases you can do on
your own, you don't need any help.
It's very, very easy.
And you go and check if the mesh are easily, yeah.
I, I use in this case a microt texture implant and not a pollutant.
And we do, as usual, we, we put inside the betadine.
And we, we just shake the, the box and, and then we remove we change
gloves, we change everything um actually before to, to,
to open the, the extra shape and then we put the implant face down as I said before that's
the inner part of the um ADM.
And And then you close the wings must be.
Adapted around the implant, but it's very easy anyway.
Couple of notes And ready to go in.
Anatomical implants.
Actually, in my department we use 100% of anatomic implant for breast reconstruction.
And that's it.
We go inside It's very easily.
No, no, no problem. 7 centimetres is huge entrance.
You can put a truck inside, no problem.
And And that's it. And then you go and close.
I use a spatula.
It's just to re drape the skin. It's very important when you use a pollutant
because the grip is very strong and you can have the,
the, the implants that comes out the chest wall, but not with the uh implant,
but anyways the airs and then I use the always spatula.
This is the day after.
Uh, you can see some, some imperfection, uh, but no problem at all,
no sufferance, no animation, and, and then now I, I will show you,
uh, the patient, the day.
One day post-op, but pre-op 6 months, 2.5 year post-op.
And uh with very good results and we we use this kind of
of um technique using this device for a lot of patients that are not so beautiful exactly
uh like this one or when you have uh like in a patient that I show.
Before, uh, the, the patient that that previous, um, breast augmentation,
usually the thickness of the, the subcutaneous tissue is very,
very thin, and then I prefer using this kind of technique more than pollutant for this case for
this kind of patient and I showed you before.
I took my time and uh actually.
Profile sorry I go back it's.
It's unbelievable, you know, you can see the, the upper pole.
There's a bulging that you don't see in, in, uh, in a poop.
It means that in at least for me it's much better than the second one,
no, it's more natural, uh, you don't see the implant, uh,
the cleavage in, uh, in the middle is, is, is fantastic.
It's, it's really so strange. You can say that the breast construction seems
an aesthetic procedure is wonderful.
It was a dream once it was it was really a dream.
Then is profile and then that's the uh.
I conclude usually this thing because if you drive it back you never go back.
It's, it's the way uh to say that if you have the possibility to can steal and
can perform on prepack previous action I think that this is a great option to use.
Thank you. Uh