We're gonna have um our next session, um, that is sponsored by GCA um by GCA
Aesthetics and the lecture given by Tamara.
Thank you very much. Uh good morning everyone,
and uh. Uh, excuse me, thank you for the opportunity to
speak at this meeting today. I, I am an industry sponsored,
uh, presenter, so my declaration of interest is that, um,
I have been given an honorarium by GCA to give this presentation.
But having said that.
We make our decisions in life and we, we choose the implants that we use and,
and as a result of me choosing the implants I've used.
I've been asked by GCA to give this talk. It's, it's not the other way around,
you know, we'll give you some money and you use our implants.
It's the other way around. I, I, I've used their implants and I've,
I've said to them, look, this is the, um, these are the results that I've got,
so I'd like to talk about my experience with uh with pearl implants.
And, and there are three parts to this presentation, my decision making,
you know, why did I start to use these implants, um, in my,
in my practise and my practise is um purely aesthetic when it comes to breast surgery.
Um, we're gonna look at data because our decisions are driven by data,
and, and what we should do is, uh, is in the best interests of our patients.
Our patients make their decisions based on emotions.
Why, why, why do I want to do this, this is why I want to do this.
And, and when we are making our decisions, we have to ask ourselves how are we gonna do it
and what are we gonna do?
And uh data forms an important part of our decision-making principles when we're
considering. Um, how we're going to address the,
the patient concerns, and then, given the data that we've got,
I'll be talking about, well, how did we get to that point,
uh, in, uh, in, in, in things like complications, revision rates.
And um What should we do to try and achieve the best possible results?
So I've been a plastic surgeon for 18 years and um actually funnily enough,
Patrick and I, we go back about 30 years, coming up to 30 years now,
so uh it's it's, it's been a while and um the the.
The the choices we make in terms of cosmetic breast surgery are related to you,
what were we taught as uh as young surgeons in training?
And I was always taught you must use textured implants because the capsular contraction rate
is much lower with textured implants than it is with smooth implants and so I started using.
Um, textured implants, and highly textured implants, um,
including the, the Allergan Natural range, um, back when I first became a consultant in 2006.
I then moved to Nagor implants, um, and, and, um, I started using,
um, and then I went back to Allergan Natural implants, including the Style 410,
which I very much liked and my patients loved the results,
and I'm still seeing my patients 15 years later and they're saying,
do I need anything done with these implants and I'm we're examining them,
we're performing any necessary investigations if necessary,
and we're still saying, no, just leave them in place.
They, they last a long time, they're they they were excellent implants.
But of course. We were all worried about ALCL and so a lot of
us moved away from highly textured implants because of this worry that we had at the time.
And clearly we're now in a much more mature position in terms of consideration of ALCL and
how uh what what are the chances of this happening and what are we gonna do?
Um, but I moved to smooth implants in 2016.
But I got 3 capsular contractions in one year and it's just not my uh my practise and I just
don't see that. So I moved over to minimally textured implants,
uh, and I started using the Motiva ergonomics implants, and now I'm using uh GCA pearl
implants. This is the reason why I, I, I don't like
excuse me for a second.
Excuse me. So this is the one, the one reason why I didn't
like the, the ergonomics implants was the um uh was the chip that they have inside,
but they're beautifully soft.
They've got a nice texture, they've got a um a minimally textured surface.
And so the idea behind that is that is that it'll reduce the risk of capsular contracture,
but it'll eliminate the risk of ALCL.
Uh, and so when, um, uh, whenever there's a new implant, we've got to be a bit careful,
you know, because. We've heard about soya bean implants,
we know about what's happened with other implants in the past,
uh, with, with uh, with, with dirt that's been found in the factories,
with um, with a recall in the US for allergan implants.
We've just got to be a bit careful when it comes to choosing a new implant,
so when it comes to using a new implant.
We really got to check it out.
We have to do our own studies, so I used in Pleo in the past and and now I'm using Pearl.
So the, the, the reason I, I, I do like pearl implants is because of the,
they are classed by the International Standards organisation as a smooth implant.
Now that might change uh later on, but certainly in uh in 2018.
That's what they're seeing, and as a result, it's likely that there is a either a 0 or an
extremely minimal risk of uh ALCL.
So I've already published um some of my experience because remember our decisions are
driven by facts. So I've already published some of my experience
with uh with the use of these implants uh and and I'll I'll talk about this.
Uh there's one other study that's been er er published.
Looking at the use of these implants, and I'll go through some of that data.
Um, and I'm working on my next, um, paper just, uh, looking at primary breast augmentation with
these implants because obviously primary breast augmentation is associated,
it's an easier operation, so it's associated with lower complication rates.
So I started using them in January 2021, just uh um just when uh the Scottish government
decided to close all cosmetic clinics. So um I I I I I made the decision to use them
in January, but I could only start using them in April.
Um and so, uh, over three years, um, I looked at uh my practise.
I, I, I run a hospital in Glasgow, uh, and we have uh a few surgeons that work there.
And we all do, uh, we all use Pearl implants. I said,
if you'd like to work with me, please do come along.
Um, well, I would love to have you there, but you have to do things,
uh, you have to use the implants that I want you to use.
Um, and so we looked at 374 implants, uh, that were implanted by 4 surgeons.
We looked at primary augmentation, secondary augmentation, we looked at primary augmentation
mastopexy, and secondary augmentation mastopexy. We, we just looked at every patient that came
in who had these implants.
And we looked at our complication rates, we looked at our capsular contraction rates,
we looked at er um er we looked at a few other aspects of uh of of of outcomes.
So, um, there were no capsular contractures in, in those cases,
um, but you could argue that we didn't really have much follow up,
but I'm gonna talk about that in just a second.
Uh, we had one infection, that's bad luck, I think, uh,
and, and 5% of our patients underwent a revision, that's 21 cases out of those 374.
Um, and we, we followed them. On average for 18 months,
which range from 6 to 13 months, and, and 18 months is not much to look at things like caps
the contracture and long term outcomes, and of course um we um we we're aware of that.
But how long do you have to look after a patient?
How long do you follow them up for before you make a decision as to is this implant safe or
not? So our our general plan is to follow our
patients up a week later, 6 weeks later, 6 months later,
we, we give them an open appointment as well.
We don't charge for um consultations uh once they've had their surgery and they,
they can come back whenever they want, and that's why some of our patients are coming back
several years after their surgery, just asking, you know,
could you check my implants?
So, um, We, this uh this shows some of the, the, the data of the
study. Um, bilateral cases for both sides, uh,
most, most, uh, types, you know, 99%.
Uh, we use the moderate profile in around about half of our cases are high profile in about a
third, and an extra high profile in about 7%, 8%.
Uh, we used an inframammary fold incision in about 83%,
that's about 7 out of 8, and, um.
Uh, that was a masterexiore reduction performed at the same time in a small proportion.
Most of our patients have subglandular subfascial uh augmentations uh when we're
putting the, the breast implant in that plane. I made no difference in this study looking at
the difference between subglandular pocket and a subfascial pocket.
Excuse me, and the difference between the dual plane, type 12 or 3.
Here we can see the age and the gender distribution, um,
and we can see primary breast augmentation formed, um,
the majority of our practise.
An augmentation mastopexy, a single stage augmentation mastopexy,
in other words, uh, formed part of, uh, formed about 16%,
and secondary breast augmentations were a smaller proportion.
So, what were our complications? Why, why, why do we do revision surgery?
Well. We performed Scar revision in 9 patients and
and these are mainly going to be in our augmentation mastopexy group and our reduction
uh augmentation groups as well.
3 of our patients had lower pull stretch, and of course this is um more likely in patients
who have augmentation, mastopexy than primary augmentation, but when you've just got 3
patients, you can't really do any stats on that.
We had one hematoma, uh, 1 infection, one patient was dissatisfied with the final result,
and we had 6 patients that the implants, they didn't quite sit in the right position,
they'd moved. Now you can ask yourself, is 18 months really
long enough when you're following up your patients to look for capsular contracture?
And um. Do you know, I, I, I actually have a lot of
time for Bill Adams. I think he, he speaks, um,
he speaks a good, uh, he talks a good talk.
I, I enjoy listening to him, and, and this was his paper when,
uh, when he came to looking at the 14 steps to try and reduce complication rates,
reduce caps the contractual rates.
Uh, and he followed his patients up on average for 14 months,
and he said look you can get down to a 1.8% risk of capsular contracture using these
various techniques. And of course, uh we use,
uh, many of the techniques that he's described, and I'll show you a video later on of what we
do. But we're trying to get low capsular
contracture rates, we're trying to get uh the implant to stay in position,
we're trying to get low displacement rates and how are we gonna do that,
so um. The um um so if he has followed him, his
patients up for 14 months, and, and, um Hendrickson has followed him their patients up
for 19 months and Tan again we're all looking at on average.
an average 2 year follow up or thereabouts, looking at capsular contractual rates,
or early capsular contractor rates. Of course,
capsular contraction can take place later on, but we know that the,
the rate of capsular contraction reduces just as the years and as the decades go by.
And what I'm now looking at is our primary breast augmentation patients,
so I just want to run through some of that data as well.
So we looked at.
235 primary breast augmentations that were performed over a 3 year period,
and again we followed them up for as long as possible, so right now it's been around about 2
years, but I think we're gonna follow them up for um maybe 3 years just to see what,
what capsular contraction rates are, what infection rates are,
what. Displacement rates are that type of thing.
And, and I looked at two surgeons in, in the hospital that I that I work at,
because you could then argue, well, if you're just looking at your own data,
well, yeah, yeah, yeah, how can I replicate that?
And, and the difficulty is replicating what other people do.
So we looked to two sessions and the reason I, I, I chose one of my colleagues is because.
He does things exactly the same way as I do, so um he's he's he's a bit more juni,
he's very good, uh, but he, when, when he first started uh working with me together,
um, uh, we, we started using the same techniques we,
we, we perform, uh, we assess our patients in the same way,
we make our decisions in a, in a very similar way, and our,
our operative procedures are performed in a very similar way,
uh way as well. So we we use small incisions about 4
centimetres long. Uh, we use sharp dissection or uh diathermy
dissection, uh, to try and ensure that there's no blood within the actual um uh pocket at all.
Uh, we use a funnel insertion, we infiltrate the pocket with antibiotics.
It's a local anaesthetic, because local anaesthetic has a,
has a bacteriostatic effect as well.
Uh, and we use a three layered closure, making sure that we're um uh using inframan we full
control sutures, um, as um as as part of our closure technique.
So 2 surgeons, me and um.
We'll call him PL Prakash is his name.
Uh, so we contributed about half to this series.
Uh, dual plane was used in 37 subfascial in, um, uh, 63%.
Um, sometimes we don't write our operation notes as well as we should,
so we don't know what it was like in two.
and we used a distribution of medium high and extra high profile in,
in, in what you can see.
Our largest implant was 520 cc and this was a primary breast augmentation.
So when you use 520 ccs in a primary breast augmentation.
That person has to have very, very loose skin, and she's looking for a a rather large result.
Uh, some of our patients were, were, were, um, described as tuberous breast.
The, uh, the, uh, definition of tuberous is, uh, is a bit contentious.
There's different ways of doing it. I like, um,
I like, um, Mark Pacifico's technique of, of determining, er,
whether someone has a tuberous breast or not.
Look at. The, the northward index.
Um, but our patient aged between 18 and 55 for primary breast augmentation,
and our average follow up was uh was 22 months. But as I say,
uh, I don't think this is long enough so we're just gonna uh wait a little bit longer before
we finally publish this.
So we've performed 6 revisions in these 235 cases.
One patient became parent and and um I'm just gonna talk about the the code that I use here.
M means medium profile, H means high profile, E means extra high profile,
SG means subglandular, DP means dual plane, and of course that's the size of the implant that
we used. So one patient just became a bit paranoid about
breast implant illness, and this was a few weeks after surgery,
in fact, one week after surgery, so I removed her implants.
About 6 weeks later.
But which that didn't help her anxiety, but at least she doesn't have implants anymore.
Uh, one person that put in 360 cc implants, she said, you've made me too big,
so we just changed them to 190 cc implants, um, about 6 months later.
And we had 4 pocket adjustments, uh, 3 in dual plain pockets and 1 in a glandular,
uh, pocket, but you can see that uh the, the woman had the,
the very, the largest implants in this group.
Her implants dropped a little bit.
So, um, Uh thankfully we've had no infections in this group,
but we had no capsular contractions and, and that's unusual.
So I wanna talk about capsular contracture and and a 0% rate of capsular contracture,
uh, in a bit more detail.
And and uh you can have a think yourself because I've obviously had to think,
you know, is there an advantage in having no capsular contracture,
or should we actually have a small degree of some complication because,
you know, your, your best qualities are your worst qualities as well,
um and um.
There's, there's gotta be something, uh, which is good about having 0% caps in the contracture,
but maybe it's not all good.
Uh, and our revision rate was 2.5%. If you take away the two patients,
one of whom wanted to become smaller, and one of them he was worried about,
um, uh, breast implant illness, uh, it becomes a little bit,
uh, lower than that as well.
So, are, are, are, are, are these implants safe? Well, I,
I, I think they are. Uh, I think, um, we're,
we're only gonna find out in a few years' time when we do a 10 year study.
Um, but there's no early evidence of any safety concerns.
Um, but the other thing is, in order to get no capsular contracture,
uh, you know, very low infection rates, very low rates of,
uh, complications, I think there are certain techniques that we have to use,
so I'm gonna, uh, I'm gonna show a video. So, um,
we, we mark the uh incision, uh, using, you know, the,
the, the arm elevation technique, you put your, your finger where the infra mammary creases,
um, you hold it in that position, you get your patients to lift up their arms and that's where
the newer IMF is going to be.
Um, we, we use a knife for the main incision just to the deep aspect of the dermis and from
there onwards, uh, everything is done by diathermy dissection.
And I like to use, uh, the setting spray 60 because I think that makes a big difference.
There's always a small vessel, uh, just around the 4th intercostal space around about the the
the midline of the lower Panchinal region, and so we have to be.
Concerned that we, we, we diathermies these vessels before we uh we cut through them.
Um, once we've made the pocket, I don't use a uh a um a no touch technique.
I use a, a minimal touch technique.
Uh, we covered the um the the nipples with a with a dressing as well,
just to try and reduce the the bacterial load going into the um into the crease.
So once the pocket has been made.
Um, I will infiltrate a solution of gentamicin mixed with local anaesthetic.
Uh, the local anaesthetic allows us to, um, uh, discharge the patient the same day,
so they leave about 2 hours after the surgery is finished.
Um, I usually say to them, look, you're coming in 1 hour before the surgery starts,
uh, the operation will take about 1 hour.
You wake up an hour later and you're home an hour after that,
so you're in for 4 hours.
Uh, we soak our funnel with, um, uh, with betadine, uh,
and, and it obviously it has to be hydrated just to activate the hyaluronic acid within it,
um, and. There are various techniques of getting the
implant into the funnel. I use my hands, some people can drop it in,
but you worry about dropping the implants.
And they're quite robust implants, um, you know, nowadays our implants are are nice and soft,
er, and there's they, they, they, um.
They squeeze quite nicely and they pass quite easily uh through the funnel into the,
into the pocket. You have to check, I think, uh,
is my implant the right uh direction, you know, is the,
is the little button uh on on the under surface because, you know,
we've all removed implants where um. Um, during secondary surgery where they,
they flipped over and and you just wonder were they placed in that position in the first place
with anatomic implants, and we removed implants where they're not quite orientated correctly
and you wonder were they put in in that way or were they um.
Uh, did they move as, uh, as, as the years have gone by.
Uh, so, um, there, there's minimal exposure of the implant to the air.
There's minimal exposure exposure of the pockets to the air,
and, and so I think these are important principles when it comes to reducing
complications because there's bacteria in the air, we can use laminar flow systems,
we can use 25 air changes per hour, we can use 27 air changes per hour.
Um, but nevertheless, there is gonna be some bacterial contamination and of course small
numbers of bacteria in a pocket in an implant are, are not good.
Large numbers of bacteria, uh, are, are even worse.
So the last thing with with relatively smooth implants, they do move around and they,
they, they don't stick down as uh as much as the highly textured implants that I've used in
the past. And and some of us have used polyurethane
implants as well. They stick um so much er differently to
relatively smooth implants.
So this uh in order to reduce the risk of bottoming out of of the of lower pole
displacement of lower displacement of the implants, I think an infra mammary fold,
um, securing suture is important. And so I uh we.
Um, my, my colleague and I, we both use a triple layered continuous suture closure
technique. Um, um, you know, there are various techniques,
and we may hear about these later on of securing the inframammary fold using a figure
of 8 stitches. Uh, but I think you, you can get about 4
stitches, uh 5 stitches into the inframanmary fold using this technique as opposed to,
uh, double techniques or or anything like that.
Um, you, I'm sure you don't need to watch me close the wound,
uh, but we're trying to do things, uh, as, uh, with as,
as, um, a nicer closure as possible. So anyway,
so three layered continuous, uh, suture technique that I use.
And these are typical er results, so this is dual plane.
Uh, subglandular, we can get some nice natural results.
Uh, with, uh, with medium profile implants, um, that's a 340,
this is a 280.
Um, and, and then of course with augmentation mastopexy, again,
we're trying to elevate the nipple, reduce the lower pole,
uh, uh, excess, um, uh, reduce the upper pole concavity that these patients have.
Uh, we know that in the, in the long term, these, even with augmentation mastopexy,
they tend to, um, uh, they tend to remain in place, uh,
particularly when we're doing, uh, lower pole, um, securing sutures.
Um, and, and these are now high profile implants.
We've used them for tuberous breasts.
Uh, we can use them for, um, augmentation mastopexy, particularly when a patient says,
I want to have upper polefulness.
And these are the extra high profile implants, and these are replacement techniques.
Clearly we've used them for uh asymmetric augmentations as well.
So, in conclusion, I think we are very happy with these implants,
uh, we're we're gonna continue to watch them and um um.
Study them, look at our outcomes, um, and, uh, we'll, we'll see how,
um, we'll see how they go, but we're doing a 10 year study now,
so we'll, I'll report back in 10 years I guess.
Thank you very much.