Thank you very much for the invitation.
Uh, this is the usual incision nowadays for personal orientation.
Uh, immediate post-op period also shows diminishment in sensory of the nipple
areola complex and in the long run at 6 months, 1 year,
complete recovery is aliatory.
There is at this point a neurovascular bundle which we believe is very
important, is the 5th anterior intercostal perforator artery
artery vein, and nerve.
Here you have the perforator.
It's a consistent finding finding, anatomical finding always present.
Navien Morris showed us the importance of this vehicle, especially.
Consider the traditions believe that they were in fascia,
uh, has the pedicle for the nipple are, and we believe it's not correct.
We believe that the 5th anterior intercostal perforator gives off a branch to the 4th in the
wording of fascia, but mainly it goes.
In the subcutaneous tissue to the nipple areola.
Area. Uh, Joe Oletti was the first to notice that
inferior pedicle breast reductions had better sensibility that superior
pedicle. So by playing with uh the inferior pedicle
Brancati realised that uh patient had uh.
Tremendous normal good sensation in the nipple areola complex.
We had the opportunity to investigate this nervous this nerve accompanying the pedicle
during superior um breast reduction, superior pedicle breast reduction,
so we could go and look in the clinical cases if the nerve was there was always there
and uh we could uh detect it quite easily with this uh.
New camera, the camera that uh doesn't need any special staining or
injection just by changing some uh philtres that you can detect the
nerve quite easily.
So each time we do uh you you put the camera and you see the nerve even if it's inside
the uh tissues.
You can detect it very easily. I think I, I can show this for a minute to show
in the screen how you see the nerve with this camera clearly it's used for other
regions like uh thyroid, etc.
so um. So, um, by preserving this, uh,
pedicle urine.
Nipple sparing mastectomy, it is quite interesting how at 6 months this patient with
the bilateral nipple sparing mastectomy and media reconstruction has a perfect normal or
even more uh sensation in the nipple.
We published this in uh PRS.
And then we thought Why when we do the breast augmentation we always
kill this pedicle.
Maybe by displacing the incision a little laterally and preserving the mere of the breast.
We could have Uh, normal sensation even in the immediate post-op period
so we, uh, made a little study comparing two groups.
25 patients, each group one with conventional incision.
Uh, the group's equal kind of patient equal BMI range of age,
everything equal or almost equal and another group with laterally displaced and then we took,
uh, sensitivity testsreer all, all the tests, you know,
at the 2nd, 14th, 1330 days and 6 months.
And Group one with conventional incision all presented all some degrees of sensory
diminution. In the 2nd, 14th, and 30 days post-op,
but group two, when later at this place, all of them had normal,
all of them normal nipplearla sensitivity, which was equal to the preoperative,
uh, sensation.
So in conclusion that we think that moving uh laterally the the incision.
Out from the central aspect is found to be associated with full sensation in the lower
pole and nipple areal complex after surgery.
Uh, we published this now accepted in the aesthetic Journal,
and we truly believe that with this evidence, uh, we should avoid central incision if you
want to preserve completely sensitivity of the nipple areola complex.
Thank you. Wow,
that's great. Next we have two back to back talks,
uh, by Doctor Konstantine Stan. The first is composite breast augmentation with
round implants and lipo filling.
Is this the new gold standard followed by tuberous breast correction with implants,
fat and tissue rearrangement. Thank you very much,
dear colleagues. Thank you very much to to be.
With us, thank you very much Gian Marlin for this opportunity to be here.
Actually my first uh talk will be a little bit different than on the programme talking about
uh the tuberous breast because on this subject I'm going to get into some details not only
about fat how to put the implant together in the way to build a new breast it's also how to.
Manipulate the tissues, uh, how to really rearrange the tissues.
I have some conflict of interest regarding the production of this implant,
some videos, a DVD, a new technology for tissue connecting, and this is not video advertising.
It's not for money. This is a book I did it for the beauty of the
breast and the pleasure of creating the beauty and.
The women feel better. This is nice.
I recommend you to do with all your patients this kind of uh beauty.
It's not about before and after it's not about surgery.
It's about what the woman feel and it's not only about the picture,
it's about the statement each patient normal one are really expressing about that tuberous
breast. It's a very important uh argument because here
we are putting together all our knowledge. It's about how to use an implant.
It's about how to do tissue rearrangements. It's about how to use the fat and the fat is
not just simply harvesting the fat put inside now everything more detail putting together.
In going to increase the capacity to rebuild this breast about 15 years ago presenting in
BTS this kind of breast, which is the most difficult breast from my point of view because
at the origin was the fibres, but then that was optotic breast where you need to put everything
to get a nice results but take a look at this picture the post-op results without scar
repositioning the tissue, adding the fat at that moment it was let's say.
By mistake or without knowing every detail how to do this,
but I understood if you pay attention to every single detail we can really rebuild the woman
breast. That's why I don't work anymore with the word
breast augmentation. It's breast reshaping.
It's breast aesthetic reshaping or this breast where I understood more and more that changing
the two. aspect of the breast recruiting more skin,
putting more content inside implant rearrangement, using the muscle to cover,
which creates more difficulties. It was able for me.
I was able to really rebuild this breast, but we need a planning.
We need to know, we need a philosophy to know how to do this inside the breast.
That's why this tuberous breast now approach it's my work.
I know that there is other method to do this. I put in a small video of 6 minutes
altogether what I'm doing.
This is the patient evaluation of the picture before understanding what is the differences
because here the difficulties, it's much higher because they are asymmetrical large in mammary
stances you are going to get into the area where if you are not.
In proper technique you're going to create a lot of bunch of complications and this is a
patient evaluation. This is a way to extend the base to lower the
position of the breast but lowering the fold, getting into the area,
recruiting the skin and for this I need to expand the skin.
That's why I will introduce in the next presentation the concept which I call tissue
expansion. External one from outside using the riotomies
or percutaneous expansion. I use this trick not jealous because sometimes
it's creating that skin damages. I'm using this non resolvable suture.
I'm lifting the tissue and now percutaneously, but a very thin needle could be Kho needle or
just a normal needle like a. Using here which is less expensive.
I try to do everything less expensive as possible, not because I'm Scottish,
I'm Romanian, but I'm from a poor country.
I'm, I'm joking. No, that is uh the story now I'm evaluating the
amount of the skin I need to use to cover the lower pole,
and that it's creating another.
Challenges the way to put the incision and that incision, if you need more skin,
must be all the time accordingly to the lower margin of the 6 ribs because if you are going
lower, you are going to expose a scar into the visible area after that once we are using a
stable implant. Then I'm doing dissection, but very accurate
using these two devices. This is the forceps.
It's a modification of John Tablets, um.
A little bit different cutting with the tip aspirating the suction,
creating a prospective hemostasis, touching the tissue with minimal damage as possible smoke
suction because working in a semi open pocket, it creates a lot of smoke that is helping and
also creating this kind of minimal invasive dissection and this is uh Alice forceps
grabbing the muscle.
Creating a second pocket, that one for internal tissue manipulation because I need to change
the footprint and the tuberous aspect of the breast, which means a lot of scorings of
glandular poinyma horizontal in the upper pole.
Then I need to get rid of some fat layer in the chasinak space which are creating the risk of
waterfall deformity.
Well if we are understanding all these small tricks we are going to improve better and
better results then I'm doing scoring scoring, it's very important 90% of the thickness of the
glandularincuma, but in the lower pole that are radial and circum areolar,
it's completely destroy the memory of. The tuberous breast and I'm cutting the old
inframammary fold where it's creating the double contour in the future risk and for sure
I will need uh to add fat at the end.
Now I'm plumping the two cavities with some gauzes to check the shape of the breast and
then I'm introducing an implant but here I can't do this with non.
Stable devices with a round one we know very well that I tried round implants.
Why not? It's easy it's easy to introduce but.
Controlling the shape of the breast, we need a device as much as possible stable,
stable in terms of the shape, stable and special in terms of the lower margin,
stable in terms of the interface of the polyuretan.
I heard here people saying polyuretan it's a texture implant.
Sorry, it's not, it's a covered implant. It's totally different stories.
It's really totally different stories and if you are using ADM.
It's the same thing that means, but that it's added in the surgical time.
This one is customised. It's create a 360 degree integration of the
tissue which keeps my implant into the right position for at least a few years
and that has created the beauty. Then the way to introduce and to manipulate the
implant inside with this bag, this is not a mayonnaise bag to introduce a round implant a
smooth one. I know we are happy when we're squeezing
immediately. It's pumping into the pocket.
No, we need to control the interface of the posterior wall of anterior wall.
We need to control the expansion by the way, I did the second dissection plan to control the
expansion because I don't want to let the tissue to control the shape of the breast.
I want my implant, which is much more stable, to control the breast shape,
and that is the differences in all these aspects.
Then I'm closing the the. Pocket and at the end I'm going to do fat
injection. I know that fat now it's a magic tool for doing
breast augmentation using a round implant. I'm going to discuss in the next subject,
but fat is not for that fat is just creating small refinement.
It's going to add some fat into the space.
I expanded with riotomy. It's going to help me for some deformities.
It's going to give me lack of.
Shapes where I don't like it because fat it's not predictable otherwise you are going to lose
what fat it's able to do and you are creating other extra uh complications.
The way to introduce the fat. I try everything in the next presentation.
I will give you my last update probably in 2 or 3 years I will change something but this is a
beauty because that means experience, how to learn from our own mistakes.
And for why not for other colleagues we are doing in in the clinic small workshop.
I'm doing this because all the time with the feedback they're coming back and they challenge
me, OK, you said the bullshit. What is this?
And I understand that sometimes we think that we are.
Not God. God is only one.
We are just humble, must be humble plus and this is the result after to get this kind of
accuracy to reshape of breast, we need to think a little bit different.
It's not about how to put an implant to create a pocket,
and that's it. And this is a final result immediately no pain,
very good stable breast and look to the patient with the picture after 6 months,
really getting rid of the memory of the old fall if.
Sometime you have a memory of a fall. Why not?
We can expand it once again to put fat again. That means from this point of view
communication with the patient can help us to really get this final results.
I'm quite finishing this and I move to the fat because probably very important part for
getting better results for this breast it's a fat injection and the way too hard was to
prepare the fat and then why not to inject the the fat.
Something very important from this subject. Number one,
going back home, we need to manipulate the parintima internal lifting with future.
I creating a lot of system for internal future. My last update which I recommend you to.
You use also in mastopexy without implant it's uh detaching the landular quaintima for the
muscle expanding vertically with horizontal scoring and with the lock or queen sutures to 0
or 0 if you want more stronger.
At the 4th rib level cage you start doing internal suture and then you replace everything
higher and higher then you go to the 5th ribs and then you go to 6th ribs.
This is completely to change the breast shape and it's giving the aspect like inside an
implant and this is very important to know the next meeting I will show you this number 2 to
go back home it's riotomy.
I have here a small. Movie to show you how I'm doing this.
I explained in the movie we do not have too much time,
but in a tuberous breast with otic appearance we need to tighten the skin to tighten the
polyhyma and the posterior wall.
I had the chance to create a special device for doing this internal modification and we
can'tighten the breast.
It's changing the consistency of the tuberoustotic breast loose tima.
much more firmness and skin reduction, a skin tightening, avoiding the external
scar in case where you have some extra skin with this device with plasma argo plasma endo
coagulation, I really am able to change to make the consist of the breast much more closer
to the young breast and that is another important advantage now we are moving to the
next presentation please.
Can you help me? And I'm going to insist a little bit the way to
prepare the next one, the presentation if you ask.
And the next presentation, it will be an extension of this one talking about this fat uh
topic. Well I try everything possible on the market to
find this. By the way, the title of my presentation here.
It was, uh, you can just swap this microphone.
The Do you think?
Uh, yeah, I'll just put this one here.
But I can use this mic.
OK, I do not just uh.
Open the presentation. Just to open the presentation,
yes. OK. Now, um, when I got the title man I look
carefully. I said wow, they're talking about composite
breast augmentation with round implants, uh, and lipo filling is this new the new gold
standard. I said I'm not using round implants actually
after a career I stopped using. I understand that something is wrong in doing
this. But then looking much more carefully I said why
not let's accept these challenges and I said round I'm doubt about this and
when I talk about the new gold standard I didn't understood that that put it something
else a question that means it's this a new standard gold.
From my point of view, not with brown implants, but that's why I'm going to insist more in the
way I am preparing the fat for injection, which could be for you a very nice way to
really make the breast much nicer at the end we know that Patrick created the story of the.
Most beautiful breast if you are training your eyes doing the breast augmentation with this
principle, you're not more able to do it all the time with round implants.
We need to go further and we need to touch up every single aspect but when I talk about round
an anatomical implant since 1992, John Tebet said put together a round and
anatomical stable implant you are going to see the differences.
If you're looking to the right breast around one, how can I control a breast shape only with
a round implants? How can I think that putting another unstable
device, which is the fact I can make a breast to look as Charles shows all the time,
the beauty of the breast that is very important from my point of view,
but then more than that, I did this test that this is 20 years ago with different shapes of
implant because around the implant is not about only the shape,
it's about the consistency of the gel. All the time around the implant must have a gel
very low consistent otherwise it's going to act totally different but looking to what happened
with this type of breast, it's easy to see that the less stable one which is falling down,
it gets out of the equation is around implants from this point of view,
I understand, OK, let's do something to use the fat as a recipe for the better breast and get
out of our comfort zone, look to our friends, and these are the fathers of the.
Flat injection and the composite breast augmentation system with then um Erico Clare in
France with uh our friend Dan Delvecchio and I introduced this concept which is called
composite breast augmentation 15 years ago again I put this presentation in.
Stockholm looking to this patient after weight loss, look to the quality of the skin using
just implant with the procedure. I really don't get the best results,
but adding the fat, I was able with a 165 implants, you see.
Anatomical one internal manipulation and fed to get this kind of results changing the quality
of the skin that means fat is not only for volume fat is for changing the
structures, rejuvenation for the face and regenerative aspect for the breast.
It's important the surgical procedure I know very well that this is a long process.
I learned from John Tebet then I moved because I want to understand the differences between
small breasts where I need to recruit the skin, which creates other challenges,
otherwise I'm not going to have to shake the breast or for larger optotic breasts where I
need to feel everything and to lift and to rearrange the tissues inside,
and that is another approach and I created a procedure I presented before called multiplane
technique where I'm doing both plane dissection behind the muscle.
In front of the muscle scoring internal manipulation and fat at the end in very
difficult breast and I know that for this type of breast we can do it without external scars
just simply adding an implant behind the muscle internal manipulation in.
Internal suture reposition in coagulation with endo technique and internal suture in the end
but sometimes it's not enough fat came later and make me to really get the best results.
I need a stable device I showed you before how I'm introducing this,
but then about the fat and this is my the standard goal.
My standard goal is based on how to make it reproducible close using the same syringes and
the tube with uh anesthesiologists €2 free waves of transferring fluids which
I'm using for fat uh fluid injection then for fat aspiration transferring in another syringes,
and that cost me €10 if you have money you can go to lipografter or you can go to other system
existing on the market, but.
Starting from the face and I understood if I'm using the face this kind of device with 1 CC
syringes without feeling 1020 syringes putting on the table.
I'm using a large syringes 10 CC. I'm transferring with the same device with the
three waves and I'm abling the face with 1 CC syringes to really reshape the face.
I have the feeling of the tissue.
I said to my mind, if I'm using to the face, why not in the breast and then using on the
movie upstairs you see how I'm using the same device for aspirating the fat for repairing the
fat just simply coagulation and putting in a sitting position.
You see now how I'm transferring from one syringes to another one and now my face is when
I'm doing. Vertical lift endoscopical one at before
putting doing the surgery I'm using these devices.
It's home use and I'm transferring the fat. I'm using now the same devices for the face,
you see, after harvesting the fat I'm decanted vertically.
I'm not using any type of uh of um.
Centrifuge and then I'm injected with cannula at the beginning I'm recommending to do this in
open without closing the pocket because you need to be sure that having not enough
experience with this device you're not going to have the fat pouring into the pocket,
but then you are aspirating to be sure that nothing left in your pocket but after you can
close the fascia. And then you go with the fat where you feel
it's necessary. It's, it's an artistical way using the fat.
You can't put the fat after some principle 10s here, 10s here.
No. Take a look to the breast, touch, feel the
pressure because this is a way to stop the injection system and this is my standard goal
now to do this and one just case is to show you in the cases studies.
Large areola. I'm evaluating for the breast.
I'm measuring. I'm evaluating how am I doing the tissue,
but then I'm going to show you the final results, the way we can expand to introduce the
fat in different areas to do the scoring internal manipulation,
but not with a round implant with a stable implant and this is a way now I'm using this.
For another cases, for example, before finishing just a moment,
you see here in large areola too the way to expand more and you see that how important are
the design the markings because nothing is by chance.
Everything must be planned scoring expansion, reducing the skin or is the parma
with internal coagulation and the way to get rid of the visibility of the fall with smaller
implants. One increasing all aspects of the breast
reducing the cocktail view, it's probably the best way in my hand to do this and really the
last one reconstructive we are in a meeting where I understood the fat is not only
volumetic, it's also regenerative replacing the quality of the tissue.
Take a look at these cases we've said uh later uh implant based reconstruction.
I'm doing two sessions of scoring. I'm injecting the fat,
but not for volume.
I'm using. Green needle.
I am injecting modifying nano it into the skin.
The 3 sessions or 2 sessions depends. I'm expanding step by step,
then I'm recruiting the skin from the thoracic technique presented by Curry with reverse
abdominal fat. Then I'm reconstructing the nipple,
and this is the final result just using two implants and fat injection.
This is not a standard or this case is where you can see how important is the fat.
Look to the scar. How nicely was improved by the fat injection
and I use also the nipple sharing from the right side because it was bigger to put on the
left side in order to get a quite nicer result that means fat in different aspects of our job
it's part it's not a gold standard it's absolutely mandatory to have it in our
armamentary now thank you very much and uh thank you for the chance to invite me here.
Next we have a couple of uh speakers, I dare call them game changers who'll be presenting on
pre-op breast measurements.
What are the important measurements to achieve a successful outcome?
The first speaker will be Patrick Mallucci from right here in London to be followed by
CharlesRandquist from, uh, Sweden 10 minutes each please.
Thank you very much, uh, forward.
Thank you, gentlemen and Jan for the invitation.
Um, it's great to be here.
And uh a luxury to be at home.
Um, so this is, these are my disclosures, as Flo has said,
we're talking about breast markings, something which I've spoken about before,
not only just in terms of planning, but really to understand.
Um, breast shape, um, and design, which is something of course that I've spoken about.
We've all been brought up with, um, the importance of the width of the breast as being
largely the determinant for implant selection, but I think probably what's been neglected a
bit more is the vertical height of the breast, particularly the lower pole of the breast.
Um, because this really is going to be determining the position of the implant,
uh, avoiding secondary deformities, uh, such as, uh, malpositions,
and it really tests the capacity of the breast. The implant has to fit the lower pole of the
breast, and that's something that we'll be focusing on.
My markings are very simple, really, um, there's nothing particularly complicated.
I just delineate the outline of the breast. I don't want to spend too much time on this,
um, the borders, and what I do, uh, or the mainly important thing is I suppose the parent
termmining. Breast width, um, I'll start determining what I
call the capacity of the lower pole, which is the inframammary fold to nipple on
maximum stretch, and I do this with the patients both standing up,
but I also do it with the patients lying down on table,
as you will see.
So there's there's nothing really um uh magic about about the market.
This is just me determining the width and standard fashion.
Um, and, um, once I've done that, this will give me an idea of the kind of uh volume that I
might uh be able to generate, um, but once I've done that,
I'm gonna switch my attention to, uh, the lower pole capacity and say,
what about that, that implant that I've selected with that width,
is it gonna fit the lower pole of the breast?
The nipple external notch distance doesn't have any role in my implant selection,
it's simply a a mark of symmetry, and this is where I start to um look at my lower pole
capacity, this, this, this um difference between uh the the at rest distance and the on
the stretch distance which we'll talk about more.
Now. Um, how much skin do you need in the lower pole,
and what are we trying to do? Remember, we've talked about this importance of
knowing how to distribute volume above and below the nipple in order to recreate something
which looks nice.
But look what happens to the lower pole, when you do that,
you get this. So how do we understand that, how do we
understand how to place the implant and how much expansion you're gonna get,
and this is the basis of my ice principle.
So really you need to know two things, you need to know the relationship with the implant and
the capacity of the lower pole.
The bit of the implant you need to know is something that we all find very easy,
which is the implant height and its projection.
Uh, and that has to be computed against that nipple to fold,
um, on stretch, which is our capacity.
What determines the IMF position, well, how you place the implant,
but also the projection of the implant because as you project,
you recruit sin from the abdomen.
That is what I call the I factor in our ice.
The C factor is the capacity and the difference between those two known as the excess,
which you'll see, and that's the E of the ice.
So, this is how you place the implant, and again, if you place it lower,
you'll have a lower fold, if you place it high, you'll have a higher fold,
it's pretty obvious.
There's a difference to how we place anatomical and round implants.
In an anatomical implant, I like to place half. The anatomical above the nipple and half the
height below, because we know that we've already got more volume below the nipple with
an anatomical. With a round implant, we cheat a bit,
we drag it down a bit in order to reproduce that volume.
So, Just in summary, there we go.
Our implant factor is the vertical height below the nipple,
plus the projection, that's the eye factor.
The capacity is the nipple to fold on stretch, and the difference between those two
values is the excess and ultimately where we will be placing our incision.
It all sounds complex, but it is very simple, and we'll work through just a few examples for
you. So here we go, we've got an anatomical shaped
implant, it has a height of 10.6.
So I want half of it below my nipple line, 5.3.
This is the projection, 4.6, so if you put those two together,
that gives me the eye factor which is 9.9.
My nipple to fold on stretch is 8.5, and the difference between those two is
1.4. So in order to accommodate that implant,
to distribute the volume how I want to distribute it,
I'm gonna have to place my incision about 1.5 centimetres below the existing fold.
This is her on table, there's the incision on the fold,
and this is the implant or the the volume as we want it distributed.
Just a couple of other examples, um, this is a very, very small breast,
and again you'll see here that we're going to choose an anatomical implant.
So I'm drawing the height of the implant, which is 9.5,
uh, and then I'm gonna draw the projection, which is 5.5,
so it's a short height implant, a small breast, and it has a high projection.
Now remember, it's an anatomical implant, so I want half of that height below my nipple,
uh, areola.
So half of 9.5 is 4.75.
And then what I'm gonna do is I'm gonna add that to my projection,
that will be my implant factor. There are my scribbling above and below at the
height that I want my implants, and when I add that to my projection,
that gives me my eye factor.
So 5.5 plus 4.75 is just over 10 centimetres, as you'll
see. Now. You'll see that in these examples I'm using de
ball points, this is a guide.
The reality is that 0.5 centimetre, a few millimetres doesn't make a difference,
it's a guide.
So, 10.25 centimetres, now I'm gonna do my nipple to fold or stretch.
You can see it's very, very stiff. I'm not getting much stretch.
In fact, it's only about 8 centimetres.
So there's quite a big difference there. There's a difference of over 2 centimetres.
So if I'm going to accommodate that implant, I have to place my incision over 2 centimetres
below the existing fold. Now. Is that a safe thing to do?
Well, the answer is it depends on the fold.
This lady has got a virtual a mast here, you can do whatever you want without getting double
bubbles, er, etc.
But of course, not all folds are the same, and you can't do this on every breast,
and you can use the Irish principle to work backwards.
If your value is too low, you're gonna have to shorten the height and shorten the projection,
so you get closer to the original fold.
This is a very different breast, it's a post-pregnancy breast,
it's already voluminous.
Um, you she only wants a small addition of volume.
We're gonna use a round implant.
This time it's got a height of 11 centimetres and a projection of 4.5
centimetres. Remember, it's a round implant, so I'm gonna
cheat a bit. I want a bit more than half below the nipple,
um, and uh a bit less than half above.
I'm gonna add my 6 to my 4.5, that gets me 10.5 centimetres as my implant
factor, and then, and then we're gonna do the nipple to fold on stretch,
and you can see that it's super stretchy.
Uh, we go up to 11 centimetres easily, so there's no change between the implant factor
and the capacity. We don't have to touch the fold.
The incision goes right in the fold.
Um, and again, this is just standard planning, just as we've done it.
Um, before and after, there you go, incisions right in the fold,
volume distributed just as we wanted it. Just a few examples of putting theory
into practise.
Um again, this is post breast augmentation.
You can see the accurate positioning of the inframammary fold and that volume distribution
that we've talked about. This is my scribble,
preoperative scribble.
I don't use. Anything fancy like that, and this is postop
again, volume distribution as we want it, incision placement as we want it,
using exactly the same guide.
Just a few other examples, recreating that volume distribution,
using the inframmory fold as a basis. It doesn't matter whether you're bigger,
smaller, principle is always the same in terms of incision placement and volume distribution.
Just a couple of much more challenging cases, and this is where it really is useful to have a
system because there are no guys here.
So by having a system, you can actually place incisions, redistribute volume in these much
more difficult cases, um, and again, using this as your framework.
Again, tricky.
very asymmetric folds, poor tissue quality.
Again, just use a guide, place your incisions, redistribute your volume.
I think this is probably the last case of these very difficult cases where you need to have
some kind of framework by which you do it.
Again, whether it's round or anatomical doesn't make any difference.
This is a round implant using the same principle.
Again, incision placement, volume distribution, exactly as we see here.
So that's my guideline to incision placement, volume distribution,
and the key to the ice principle. Thank you very much.
Thank you, Patrick, very clear and thank you for staying on time,
uh. Doctor Charles Rehnquist is going to go over
his thoughts on pre-op measurements, what's important so that we can achieve a successful
result. Thank you, thank you for the kind.
Introduction.
Yeah, thank you very much for having me here.
Good morning, everyone.
So I'll try to share some of the concepts that I've developed uh for the last,
there were supposed to be some glasses here that I forgot,
no problem, that I've um had within my practise. So this was my assignment.
These are my disclosures.
So this is my academic take on this uh topic.
We all try to strive for the most beautiful breast and obviously numbers may assist you.
Even Leonardo da Vinci use numbers and I'm using the golden ratio and the divine
proportions. And it's 12 122 + 1 is 33 + 2 is 5,
etc. etc. and finally we'll reach the beautification
through 1 in relationship to 1.618.
That is the goal, and I do believe that the beautification of the breast is found in its
lower pole. And it's balance between breasts width,
nipro complex and IMF.
So this is what a textured form stable implant does.
It gives you a controlled tissue expansion and stability over time.
So by using a textured device, you might have to address this different and a smooth because
they act different. A nano smooth implant has an uncontrolled
tissue stretching, softer free floating breasts with less stability.
Therefore, you need to adapt.
To that type of device.
So I developed some guidelines and very simple, these guidelines are based on the base
width of the implant. So if you do have a base width of 12.
Subtract 3.5 centimetres from that device.
If you have a smooth.
Subtract 4 centimetres from the wid. So 12 minus 3.5 is 8.5 with the textured
12 minus 4.
It's 8 and it's smooth and why is that?
Because I'll show you with the numbers, the initial stretching in the lower pole.
Creates a different scenario initially.
So that's a very simple solution.
Now you might address this well if we have more projected implant,
don't we need to add more in the lower pole? No, because in a tight pocket,
that extra projection will stretch.
So this is very simple.
You measure the base width.
And based on that, depending on if you have a textured or smooth device,
if you go for textured, you can narrow that no touch zone to 3 centimetres.
Why? Because it's more stable if you use a smooth
device, that no touch zone in the centre should be 4 centimetres.
And based on the chest wall, you find what you think is appropriate from the anterior axial
line to that lateral border of the no touch zone.
Now, like.
Patch us addressed this is where it gets tricky. Where do we put that incision,
that scar in the lower fold.
Well, depending on what type of implant, like I said, subtract 4 or 3.5,
but this has to be done under the maximum stretch.
This is crucial.
If you just measure and you don't do that under the maximum stretch,
you will run into problems most likely having that breast look bottom out.
So on the maximum stretch, you can lower that fold and as you can see,
I'm lowering the fold 6 centimetres wide?
Because she doesn't have a fold. She's got applay mom,
so I need to create a new breast.
So with that said, If you know, the wid, subtract, and you'll be fine.
Now, how do I know this?
How do I know this is not just my opinion?
Well, because I'm a number guy and I measure my patience over time.
So looking at the data, looking at 1,447 patients, we measured them prior to
surgery on the maximum stretch, and depending on the implant,
how much those breasts were stretched over time.
So this is after 6 months with an average of 30 year old lady,
58 kg, two children with an average weight of 3 to 1 grammes,
and we came up with a difference of approximately 1.5 to 2 centimetres.
Now why is this important to understand, because if you do give guidelines,
how do they hold up over time?
And this shows the stretching with the texture device and you can see it's quite a straight
curve. So I know depending on the implant, it will
stretch more or less, which is quite logical.
Bigger implant will stretch more, there's more volume in the lower pole.
Now with the smooth device, there's a different scenario.
They stretch initially, and they stretch more uncontrolled.
Now Why are these numbers important? Well, if we look at numbers,
and I was looking at 4680 implants, and most of those implants that we're using range between
11 and 13.
And the average implant in the national when you talk to manufacturers is around 12.
So with that said, looking at the pinch test, average 2.68 centimetres plus the average
implant, which is 12, gives us a number of 14.68.
14.68 divided through the golden ratio is 9.
12, textured average size 300 minus 3.5 is 8.5, stretched to approximately
9 after 6 months.
So these guidelines correspond to the golden ratio.
It's math. And it works.
So with that said, proportion size decision ABC base width gives you the indication for choice
of implant width, upper chase volume desire indicates choice of full,
medium or low height.
If desire for more volume, always go for more projection.
Don't compromise and win.
So very simple, tall, narrow chest, tall implant.
Most patients do very well with a round footprint.
La, a more resent one.
So these are the charts that I've developed to get these numbers.
And when I do this, I measure all these patients, and I put that data down on those
charts. Now if I take an example like this,
this is a thin patient Aplaiaum, a lower default 4.5 centimetres on one side,
3.5 on the other side.
She's got an implant that gives her more projection in the lower pole.
Why? Because she needs that volume, and it's planned
for a 12 centimetre.
And this is 6 months down the road.
I think she's got a fairly balanced breast.
I've been able to create something that I think looks.
Proportion well balanced.
This is with a smooth device, going through a smaller incision.
And this is initially when I started using them, uh, sub muscular,
this is after 6 months, so I'm able to create regardless of if it's smooth or textured and
a proportional look depending on the constitution and the biological features they
bring to the table. Now, this is 4 years down the road.
Smaller implant and as you can see, it makes a big impact even with a thin patient,
if it's proportional for her chest width. She's a small patient.
And because I'm not blowing the fall that much and I've got the controlled pocket dissection
with the Cooper's ligaments and I'll share that later on this afternoon,
I'm able to create an environment where that implant doesn't naturalise or go more
distal. This is a sub glandular placement,
which is the way I'm doing this today with the 310, the same thing two years down the road.
You need to follow your patients over time.
If you don't, you don't know what you're creating really.
Now, the pragmatic conclusion.
I've done all these number games and they work well, but this also works very well.
For those who want it very simple, always subtract 4 centimetres from the width of the
implant, regardless of what implant you use.
And you'll do well.
For those who want it very, very simple.
If your IMF is somewhere between 7 and 10 below the nipple on the maximum stretch,
put the incision there and you'll be fine, because most implants you're using range
between 11 and 13.
If you want this very, very, very simple, for those who want it,
put all your IMF incision falls on 8 below the nipple on the maximum stretch,
and you'll still do well.
And that's a number game based on what the industry sells us.
However, You pave the road you walk on, it's your decision how accurate you wanna be.
This is a very simple guideline at the end of the day,
measure your patience and with time you'll learn what works in your practise.
This is done in Kruger effect.
We all think we're masters initially and then we lose faith,
but then hopefully we'll regain some of it.
With that said, thank you very much for having me here.
OK, and our last talk in this section is by Doctor Marco Ajo,
and he'll be talking on breast augmentation in the Asian women.
So, uh, it's great to be back in London press meeting and thanks Marlene and Gian for
organising a great meeting for allowing me to see all these great speakers and allow me to
indulge on my little journeys after hearing all this game changer.
Uh, my talk is really about how patient modified my work in breast augmentations,
um. Aesthetic surgery is no different from any
other thing in this world, there's a supply and demand, and if the demand is there as a surgeon,
if I can do something safely.
what I think is right for the patient, I will proceed and it seems that everything built on
each other. And being a few, one of the few Chinese
surgeons in London, and with the massive influx of relatively rich Chinese students coming into
the United Kingdom to study, they seem to embrace cosmetic surgery a lot more than the
older generation, and they do have a lot more money to spend.
And one of the operation they look for is breast augmentation.
I am not an expert in this field, and I do quite a bit of it.
And in general, Chinese patients are no different from any other patients.
We are not aliens. We look for the same thing.
They generally just want a bit bigger, they want a little bit of upperpolefulness.
They don't want it too big. They don't want animation because people might
notice them and therefore, you try to avoid putting in the muscular plane,
but most of them are relatively thin.
But the main thing they seem to be very keen on is small scar.
And it was fortunate in the sense that when I was looking through anything that can help me
to make more scar, there was a time when I saw pick a motiva,
and because it's a battlefield implant, it's softer, it's easier to put in,
and to have a narrow light to retract it in Califonel.
All these helped me to now make more scar, as Charles could even do it big better than I
could when in his talk the other day.
I now make around 2.5 to 3 cm.
Yes, it may take me longer, but they all seem to be happy patients.
And now, the work on that brings a lot of patients coming to see me.
And the first question they ask is that, instead of saying that you do breast
augmentation, they say, you're one of those guys who does more scar breast augmentation.
So, things changes is simply what goes out that if you make a small scar patient are happier.
Obviously, some of them want bigger implants, and some of them want a little bit more
contouring because of some asymmetry and the technique of fat transfer does help us to
correct that minor deformity on one side.
Now, with the changes in breast implant, with these negative press that's been going on
social media, some of them are not keen to have a breast implant,
even though they would like the breast enlarged.
And fat transfer is definitely one of the techniques that I'm doing a lot more nowadays
because some patients don't want uh an implant, they just want an enlargement with natural
products. And like anything in this world, if you got the
supply, I can do it better. So if you've got patients like that,
you get a reasonable amount of fat, you can launch it to a reasonable size or maybe in two
days, and you get some very happy patients.
And if you don't have enough, you get a smaller increment.
So that's all for all what I'm shifting more to now to do fat transfer.
But with this Asian group, it seems that dieting and being thin is the national hobby.
And these are the people that have been inspired by actresses or social media queen
like this, to walking in with an arm really relatively thin and not a lot of tissues.
And it doesn't help by statement made by the psychologist in uh Singapore saying that good
woman should not weigh more than 50 kg. So they're becoming more and more obsessed and
more and more patient walking in with no fat whatsoever.
I mean, I don't know when any of you have seen this on TikTok.
I mean, there's a currently a very clever thing called A4 Challenge that if you can hide your
waist behind the A4 piece of paper, you are a good woman.
Or the other thing is an iPhone 6.
So this is now become a pandemic in Asia that people are just wanting to be thin.
But at the same time, they wanted to have best enlargement.
So my consultation with these patients seems to be getting more difficult because I really need
to spend more time to figure out whether, are they just looking for liposuction or are they
looking for augmentation, or are they really looking for both things.
So, it's trying to figure out which group to put them in and what we're trying to achieve.
This is probably my average Chinese patient that walking in with not a lot of fat,
and they do want the breasts enlarged.
So, this is how they make me start thinking, and say,
well, how do I get more yield or how do I make whatever injected stay longer.
And this is my little journey that I'm trying to figure out what exactly are the best things.
Looking at the paper out there is pretty standardised, there's a lot of variations and
no one seems to agree on anything.
And this is one of those wonderful paper that was published,
and that's why I like LBM. If you look at the list of the author,
most of them have spoken at LBM including our current scientific advisor.
But if you read through the paper, it looks like these great experts in this world,
none of us, none of them could agree on how to achieve better results or better survival rate
of fat transfer.
So I then look through my patient, what, what can I do?
Can I increase the fat volume? Well, Giving them a burger is going to be
harder than feeding them with two grains of rice, I mean they would never do that.
So nutritional level is very difficult.
Some people suggest hyperbaric oxygen, but where am I going to get them to do it?
So, I try things that are more amenable to them. For example,
like fish mole, bird's nest, these are the things, Asian delicacy that's supposed to
increase the collagen and skin texture, but hopefully, all these positive things will help
with the survival rate.
And there's uh medication out there that you can give them to take like MD.
Um, skincare that would that give you about a month's supply of tablets to give you all the
nutrient, hopefully make you, uh, make all the survival rate better.
Then the next thing is, where can we harvest the fat?
Well, looking at all these papers, there's no consensus as to any way it's better than the
other. And in my average patient, abdomen is usually
the first place I go for, followed by flank and inner thigh.
Those are the common sites where you get the most amount of fatty tissues.
But in Asian, when I look at my small series and data,
I find that the place where harvest the most amount of fats is actually the electro thigh.
Not that they have more fats in those areas, but it seems that the obsession with being thin
makes them more likely to want the amount of uh tissue removed from the later thigh because
they Feel that the androgynous look is much better than the curvious look,
because in most cases, I hardly find anything in the abdomen and I just don't want to give
them more scar. I can't even get more than 50 cc.
So that's one thing I changed for them is mainly the first site I go for is the electro
thigh and then the posterior flank. Those seems to be the two main areas get most
amount of fat. The only thing I find that all these experts
concurred on is that wet technique is better than dry or super wet.
Then there's this controversy about local anaesthetic.
I mean, is it toxic? Is it not toxic?
And in the case where I have limited amount of fat that I can harvest,
I've decided that I'm gonna remove local anaesthetic from my infiltrate.
And I have to apologise for my first few patients.
I did that because they weren't very comfortable after the surgery when they wake up
for anaesthetic. So now I've changed it to when I harvest the
fats, I don't put local anaesthetic, I just put adrenaline.
In the bag of saline, and then harvest the fat, and then I put a second bag of fat with local
anaesthetic and saline in there and infiltrate after I finished harvesting.
And they all seem to feel a little bit better with less pain.
I'm not saying I'm right or wrong, but if local anaesthetic has any effect on the survival rate
of fat, I'd rather removed it and get a better yield and better survival rate.
Now, as to what container that we use to harvest it,
I think is once again, is one of those things that people argue is what's available to you.
I personally like revolve because I find nurses understand the system about washing,
centriaging it better than any other thing. Some of Things I found the uh substance is just
too wet and you're injecting more fluid and fat into it.
And patients become more disappointed because as they wake up,
it's quite swollen and then it's actually disappears simply because of loss of the uh
infiltrate. And then there's this group of saying what
exactly is the best, whether it's centrifusions or filtrations.
And looking at the data, it seems that uh filtration is better,
so that is why I like using revolve and This is how things get dictated in my practise because
I'm still trying to find out what exactly is the best things.
Now, as to the size of cannula, people talk about a smaller cannula,
leave you a narrower infiltrate and therefore, the survival rate is better.
But then I find that if I use a very narrow cannula, Especially we're harvesting a lot of
fat, there's always some fibrous tissue blocking it,
and I end up losing a lot more than it. So now I use cannula around 2.1 to 2.3.
I know it's bigger, but I feel that if I do the motion a little bit quicker,
I'm still leaving a narrow uh uh infiltrate and hopefully, and less pressure and therefore
less damage to my fat.
01:00:00.659 --> 01:00:04.810 And afterwards, it's not a lot different. I use a supportive bra but non-compressing.
01:00:05.110 --> 01:00:10.280 I'd ask them not to do any exercise for, or any heavy lifting for six weeks.
01:00:10.629 --> 01:00:14.560 And after listening to Philippe's talk yesterday, I'm now gonna start looking at any
01:00:14.560 --> 01:00:18.489 dietary things to improve the cell maintenance at the end of the day.
01:00:20.030 --> 01:00:24.110 So these are some of my data, some of my photographs, 6 months later.
01:00:24.479 --> 01:00:29.310 So, patients seems to be happy. I'm not saying I'm doing a great job,
01:00:29.840 --> 01:00:35.389 but As Charles said, everything is based on science, and we need data.
01:00:35.510 --> 01:00:40.540 And I, I totally agree that I need to find more data to support why I'm doing this.
01:00:40.790 --> 01:00:45.989 I have no idea what I'm doing it right, but I just look for all the evidence on the internet
01:00:45.989 --> 01:00:49.379 and all our journals to figure out what will work.
01:00:49.590 --> 01:00:54.709 And unfortunately, with a small practise in London, it's very difficult to do measurements
01:00:54.709 --> 01:00:59.919 afterwards, you see, the amount of fat I infiltrate versus the survival rate in 6 months.
01:01:00.360 --> 01:01:03.370 I mean, I don't think patients will pay for an MRI scan,
01:01:03.659 --> 01:01:06.649 and I don't think I can afford to do that for every single patient.
01:01:07.699 --> 01:01:13.510 But I would really love to find out more data or anyone can collaborate to do more in to find
01:01:13.510 --> 01:01:15.179 out more information on this.
01:01:15.590 --> 01:01:22.530 So, Patients and changed my way of operating, and it's a simple thing in a way of moving fat
01:01:22.530 --> 01:01:27.439 cell and trying to move the survival, but it's one of these new thing I feel is very exciting,
01:01:27.770 --> 01:01:32.040 but there's still not enough science behind it to figure out what is working well.
01:01:32.129 --> 01:01:33.129 Thank you very much.
01:01:39.169 --> 01:01:43.389 If we could have the panellists my thanks to all the speakers.
01:01:43.489 --> 01:01:46.399 Could we have you up here for the panel discussion?
01:01:46.770 --> 01:01:52.449 And apparently there is no 10:20 p.m. uh Am sponsored symposium,
01:01:52.610 --> 01:01:56.689 so we can have a little extra time for the uh discussion.
01:01:57.100 --> 01:01:59.610 Uh, I have a question for each of you.
01:02:00.179 --> 01:02:05.879 Uh, Claudio, I'm very familiar with the paper you published in ASJ.
01:02:06.699 --> 01:02:10.889 The, uh, first rule of anatomy is variation.
01:02:12.800 --> 01:02:17.399 Claudio, Claudio, sorry, Claudio, are you, did you hear me?
01:02:17.479 --> 01:02:22.229 The first rule of anatomy is variation in your 6 o'clock.
01:02:22.760 --> 01:02:28.679 How much variation did you see? Uh, was it consistently there?
01:02:28.800 --> 01:02:31.629 Did it move a few millimetres either side?
01:02:32.479 --> 01:02:38.429 Well, uh, uh, a few millimetres, OK, perhaps, but it's always there.
01:02:38.760 --> 01:02:41.409 It's not. Me is man shot.
01:02:41.489 --> 01:02:45.199 I believe in car man shot 1889.
01:02:45.770 --> 01:02:46.770 He put that.
01:02:47.760 --> 01:02:54.429 Perforator there, uh, skin artery in his lamina and uh and
01:02:54.429 --> 01:03:01.360 then salmona and uh other very good if you're doing a secondary
01:03:01.360 --> 01:03:06.350 procedure and someone uh put the uh incision more centrally,
01:03:06.550 --> 01:03:09.570 do you go through that one or do you go more lateral?
01:03:10.459 --> 01:03:14.489 No, if you have already that incision done before, uh,
01:03:14.590 --> 01:03:20.159 uh, we, we go in the same incision, but, uh, initially if you put the incision there you
01:03:20.159 --> 01:03:25.540 will kill the nerve. Constantine, you showed some spectacular
01:03:25.540 --> 01:03:28.939 results. There have been reports of implants being
01:03:28.939 --> 01:03:33.189 removed with fat in them, so two questions for you.
01:03:33.330 --> 01:03:37.580 I saw you doing your fat grafting with the implant in place,
01:03:37.909 --> 01:03:40.705 and I think. I think I heard you say that sometimes your fat
01:03:40.705 --> 01:03:47.564 grafted first and then put in the implant, so comment on how often you do each of those
01:03:47.975 --> 01:03:54.645 and also when you're grafting around the implant what precautions do you take?
01:03:55.334 --> 01:03:59.804 Well this is a very good question and the answer will be quite difficult,
01:04:00.254 --> 01:04:07.094 but considering first primary cases and we not so experienced with the
01:04:07.094 --> 01:04:11.810 fat injection. I will start first with the implant inside
01:04:11.810 --> 01:04:17.610 knowing the area where I need to improve the thickness and the shape and the contour of the
01:04:17.610 --> 01:04:24.330 breast, and I will not close the pocket behind really
01:04:24.330 --> 01:04:30.540 checking if some fat because also of my technique changing the posterior wall of
01:04:30.540 --> 01:04:36.689 glandular per incuma with scoring, increase the risk of fat to get into the pocket and at the
01:04:36.689 --> 01:04:38.129 end I will use uh.
01:04:38.550 --> 01:04:40.139 And plastic.
01:04:41.500 --> 01:04:46.919 aspiration to check if some fat is still inside.
01:04:47.250 --> 01:04:52.639 After that, having more experience and having the tissue a little bit more thicker,
01:04:52.909 --> 01:04:59.610 I will do it also close because sometimes the fat is getting out from the
01:04:59.929 --> 01:05:01.810 area to the incision.
01:05:02.479 --> 01:05:09.070 You can use also extra hole incision, but I try to put as much as possible a less
01:05:09.600 --> 01:05:15.800 access point. I will use a round cannula tipped or
01:05:15.800 --> 01:05:22.709 tapered, having all the time the tip of the camera and the concavity towards the skin,
01:05:23.000 --> 01:05:26.479 not to the perma. I will inject the fat.
01:05:27.489 --> 01:05:34.179 Withdrawing and I will always with the other finger I will touch the skin to see
01:05:34.179 --> 01:05:38.260 also. The pressure created from inside, once we are
01:05:38.260 --> 01:05:44.820 going to get over of this feeling and over expansion, you are going to lose
01:05:44.820 --> 01:05:46.060 to lose fat.
01:05:46.760 --> 01:05:52.790 And all the time be careful and be ready with an implant on the table to changing if you are
01:05:52.790 --> 01:05:58.469 doing not the composite fat composite implant fat injection that means in getting the fat
01:05:58.469 --> 01:06:03.669 into the implant, which is a mistake uh Patrick and Charles,
01:06:03.830 --> 01:06:10.750 you both showed some spectacular result in what I call flat chested patients with
01:06:10.750 --> 01:06:15.580 no one no appearance of an inframammary crease or fold.
01:06:16.159 --> 01:06:20.050 In those patients I would have gone transaxillary with them,
01:06:20.409 --> 01:06:26.540 uh, so the question for both of you any role for the transaxillary approach with or without
01:06:26.540 --> 01:06:33.159 the endoscope in your practise and be other than what you already showed any other
01:06:33.159 --> 01:06:39.699 special precautions in someone who doesn't have a crease because you both showed spectacular
01:06:39.699 --> 01:06:43.629 results. Well, in my hands for that, you wouldn't want
01:06:43.629 --> 01:06:45.820 to do a transaxillary cos I've never done one.
01:06:46.520 --> 01:06:48.629 So, so the answer is no.
01:06:49.780 --> 01:06:53.610 Um, yeah, no, I, I mean, yeah, of course I know the technique,
01:06:53.649 --> 01:06:59.239 but actually I think it's the opposite. I, I think this is where you really need the,
01:06:59.290 --> 01:07:06.040 you know, the IM incision to be able to determine and position uh the your implant.
01:07:06.050 --> 01:07:09.399 I think with the transaxillary, I think you've got less control.
01:07:09.840 --> 01:07:14.879 So I think this is where the inframfold really, really is important in those flat chested women.
01:07:15.169 --> 01:07:17.040 As long as you place it correctly and you've got to have a,
01:07:17.169 --> 01:07:21.709 it doesn't have to be my method, whichever there are lots of methods described for uh for
01:07:21.719 --> 01:07:24.810 for calculating where that fold is, as long as you have a method,
01:07:24.820 --> 01:07:27.399 a guide, uh, I think that's what we've gotta do.
01:07:28.010 --> 01:07:31.010 Charles. Yeah, so, so I was trained, blunt,
01:07:31.129 --> 01:07:32.929 axillary, we used to do that.
01:07:33.969 --> 01:07:39.929 And uh then um when I got my hands on the 40s, mid 90s,
01:07:40.060 --> 01:07:43.889 I started doing it, doing axary uh endoscopic.
01:07:45.350 --> 01:07:48.350 However, the problem with that, uh, there were two.
01:07:48.469 --> 01:07:53.469 First of all, I didn't have the control of the pocket the same way because the implant had a
01:07:53.469 --> 01:07:54.570 tendency to create that.
01:07:55.709 --> 01:08:01.459 But like Pat pointed out, when I looked at my results in these flat patients,
01:08:01.550 --> 01:08:07.429 I wasn't able really to get that perfect crease because one of the things when you do the
01:08:07.429 --> 01:08:12.510 attach. There will be scar healing and uh with uh for
01:08:12.510 --> 01:08:18.339 10s at that time the scars were around 3.54 centimetres you're able to create that crease
01:08:18.709 --> 01:08:20.709 looking at the the post op.
01:08:21.790 --> 01:08:24.990 Of the axillary approach I didn't get that perfect crease.
01:08:25.029 --> 01:08:28.419 I had a slight curve instead and I just didn't like it.
01:08:28.430 --> 01:08:31.500 It wasn't there wasn't a clear definition of the breast.
01:08:32.200 --> 01:08:35.439 And obviously that's why I shifted um.
01:08:36.200 --> 01:08:42.470 To the IMF, uh, doing what I'm, I'm doing today in general with texture with that said,
01:08:43.040 --> 01:08:48.759 uh, I do believe absolutely there is a role for acts or approach in a lot of cases but not in
01:08:48.759 --> 01:08:53.159 these cases. Mark the same question for you.
01:08:53.528 --> 01:08:59.079 We don't have as many Asian students in Atlanta, but we do have an Asian community,
01:08:59.369 --> 01:09:04.838 and they actually come in asking for the uh trans axillary approach.
01:09:05.008 --> 01:09:11.568 We also have a very large, uh, African American community that fear colloids.
01:09:12.069 --> 01:09:18.180 So at least in our city, the transaxillary approach is alive and well,
01:09:18.189 --> 01:09:24.660 maybe not as popular as it was in the 9 and uh in the 1990s.
01:09:24.669 --> 01:09:29.540 So question for you would be the same with your Asian population,
01:09:30.069 --> 01:09:33.819 do you offer them transaxillary? Do they ask for it,
01:09:34.859 --> 01:09:37.939 um. Well, when I first started my practise, I mean,
01:09:38.069 --> 01:09:43.310 the Asian population definitely asked for transaxylate because that was the in thing in
01:09:43.310 --> 01:09:45.850 Asia. I mean, you put a small scar on transaccia,
01:09:45.910 --> 01:09:50.990 you use a saline implant, you put it in and then you expand it so the scar can be extremely
01:09:50.990 --> 01:09:56.330 small. And Personally and also being trained here and
01:09:56.330 --> 01:10:01.850 part of time in Asia, I learned how to do the infra memory fold and if you ask me which way I
01:10:01.850 --> 01:10:08.330 prefer, I prefer the infra memory fold because I think uh I get a better control and better
01:10:08.330 --> 01:10:12.000 positioning of everything while the other despite having endoscope,
01:10:12.250 --> 01:10:17.799 I always find it I don't do it as well but just personally not being very skillful.
01:10:18.370 --> 01:10:23.430 But I think the changes now is because that the younger generations,
01:10:24.549 --> 01:10:31.229 the fashion may be changed is what they want to wear and What the Koreans have been doing,
01:10:31.310 --> 01:10:37.189 I think they are the major influence over in Asia and because these students or internet
01:10:37.189 --> 01:10:39.939 social medias and now they actually want to come here,
01:10:39.950 --> 01:10:42.140 provided you can make a small scar.
01:10:42.899 --> 01:10:47.200 They are very happy and they actually rather hid in it because they will never really quite
01:10:47.200 --> 01:10:50.640 take the top off, but they know with the type of clothes they wear,
01:10:50.680 --> 01:10:53.640 even if you have a scar that doesn't heal well when you lift it,
01:10:53.759 --> 01:10:59.669 you are going to see it. And then before I turn it over to Doctor Kim,
01:11:00.029 --> 01:11:06.700 one question for all of you, who on the panel uses TXA in the local infiltration and
01:11:06.700 --> 01:11:10.060 or systemically in your breast procedures?
01:11:13.040 --> 01:11:17.470 Are you and I the only 2345, good.
01:11:18.330 --> 01:11:23.379 6, I'll turn it over to you, but I think Moe had a question as well.
01:11:24.759 --> 01:11:27.629 OK, I'll just a quick question for, I mean, I've got a bunch,
01:11:27.700 --> 01:11:31.100 but we'll let the panellists kind of like that the moderators shaking it.
01:11:31.470 --> 01:11:36.569 Charles, you know, John Tebbits towards the latter part of his career really was opposed to
01:11:36.569 --> 01:11:40.490 using high profile or extra high profile implants, but you've mentioned that you still
01:11:40.490 --> 01:11:42.779 occasionally will use high profile implants.
01:11:43.180 --> 01:11:49.729 What's your philosophy, you know, comparing the long term consequences of high profile devices
01:11:49.729 --> 01:11:53.200 versus the moderate profile devices now do you prefer?
01:11:53.370 --> 01:11:57.279 I'm, I'm sorry, I don't where, where do I use high profile?
01:11:57.410 --> 01:12:01.439 Oh, I'm sorry, I thought I heard maybe during your presentation if they wanted more
01:12:01.439 --> 01:12:07.339 projection implants basically today with the CPG I'll go uh 22,
01:12:07.350 --> 01:12:12.089 which is not a high profile and with smooth I.
01:12:13.259 --> 01:12:17.330 Rarely do more than Demi, so no, I'm, I'm not a high profile guy,
01:12:17.839 --> 01:12:21.319 sorry misunderstood, but let me, uh, can I add something?
01:12:22.399 --> 01:12:26.220 No, I was I was gonna say, but I think, I think it's uh.
01:12:27.790 --> 01:12:31.680 Uh, look, I, I have a slight issue with that question because,
01:12:32.169 --> 01:12:38.279 um, it's not that a high profile device is bad, a big high profile device might be bad,
01:12:38.569 --> 01:12:42.410 but all it is is shame, you know, it's no different to varying height and width in
01:12:42.410 --> 01:12:43.919 anatomical implant.
01:12:44.220 --> 01:12:48.839 So this idea that a high high profile implant is a bad thing is not right.
01:12:49.250 --> 01:12:53.810 If you have a small high profile implant in somebody who's anatomy.
01:12:54.134 --> 01:12:57.654 And determines that that's the best shape for them, then use it.
01:12:57.995 --> 01:13:00.075 Nothing wrong with that. And the, the, the other,
01:13:00.115 --> 01:13:06.354 the other paradox is that a high profile round implant is more similar to an anatomical
01:13:06.354 --> 01:13:10.044 implant than a low profile implant because it has a shorter height,
01:13:10.395 --> 01:13:13.875 so it tends to occupy more of the lower pole, so.
01:13:14.740 --> 01:13:20.770 By paradox, sometimes if I want a more natural look when I have to use a round implant,
01:13:21.060 --> 01:13:25.060 I'll use a higher profile than a lower profile, and that's a paradox that a lot of people don't
01:13:25.060 --> 01:13:28.180 think about. But this idea that high profile round implant
01:13:28.180 --> 01:13:30.169 is bad, is nonsense.
01:13:30.919 --> 01:13:33.169 I don't think that was what Maurice was saying though.
01:13:33.580 --> 01:13:37.209 I, I'm not saying Morris. I'm just saying the the the Tebet's question.
01:13:37.220 --> 01:13:42.089 I had a chance when I visited John Tebez to discuss about this,
01:13:42.500 --> 01:13:43.580 he said that.
01:13:45.750 --> 01:13:51.910 implants, anatomical one, you need to avoid to use extra projected because I'm not able to
01:13:51.910 --> 01:13:56.589 keep the projection as able in silicone gel implant.
01:13:56.950 --> 01:14:03.430 We in Europe, we had the chance to have higher and higher cohesive gel like cohesive memory
01:14:03.430 --> 01:14:08.629 gel free or an allergan, including dual gel 510.
01:14:09.270 --> 01:14:15.729 More projected implant it's able to be useful but proportionally with the width and height
01:14:15.729 --> 01:14:21.750 once the gel inside is more stable and the shape of the implant and I noticed in empty
01:14:21.750 --> 01:14:25.430 ptotic breast or pseudototic breast with extra project.
01:14:26.259 --> 01:14:32.669 You can feel better in the lower pole and to sometime avoid external scars.
01:14:32.790 --> 01:14:35.350 That means everything is in the proportion.
01:14:35.709 --> 01:14:39.229 I think what's important if you use a high profile implant,
01:14:39.270 --> 01:14:42.189 and I'm not a big user because that's not my patient population.
01:14:43.089 --> 01:14:48.700 Uh, I, I think with the texture you have the stability with the texture device so that read,
01:14:49.250 --> 01:14:55.080 but with the 468, which was the old saline smooth if you had a lot of water,
01:14:55.089 --> 01:14:56.970 the water pillar really pushed down.
01:14:57.319 --> 01:15:02.560 The envelope and and we had problems with that and that's a problem with the smooth saline
01:15:02.560 --> 01:15:08.500 implant that's the combination of really a lot of push in the lower pole and I think that's
01:15:08.500 --> 01:15:10.250 where John's statement came from.
01:15:10.620 --> 01:15:16.979 But also another important thing what John Cabet said and always said that is the last
01:15:16.979 --> 01:15:18.959 conclusion, never say never.
01:15:19.450 --> 01:15:22.649 When I visited him, he said about dual plane technique.
01:15:22.930 --> 01:15:27.240 Don't use dual plane technique Type 2, Type 3, or type 2.
01:15:27.569 --> 01:15:31.919 Stay only in 80-90%, just type 1.
01:15:32.169 --> 01:15:37.240 We in Europe, we did a big mistake moving to type 2 or type 3,
01:15:37.330 --> 01:15:39.609 but not with small temperate.
01:15:40.029 --> 01:15:45.180 as John said, with big implants and that completely destroyed the muscle,
01:15:45.509 --> 01:15:50.819 transformed the dual plane type 3 in a sort of dual plane type 4,
01:15:51.049 --> 01:15:57.700 even this advocated by some colleagues and that completely destroyed the muscle and
01:15:57.709 --> 01:16:00.189 destroyed the concept of the dual plane technique.
01:16:01.080 --> 01:16:05.810 So it's, it sounds like right now you still prefer kind of a dual plane one.
01:16:06.259 --> 01:16:12.379 With dissection between the glandular poinyma to control expansion that was the way I changed
01:16:12.379 --> 01:16:16.060 a little bit and when I met John discussing about this,
01:16:16.140 --> 01:16:22.700 he said makes sense, but it was 2014 when I developed and I
01:16:22.700 --> 01:16:26.770 resented this concept as he said it's too late for for me to change.
01:16:27.240 --> 01:16:30.830 But Charles kind of prevents a subglandular at this point,
01:16:30.959 --> 01:16:36.390 so what are your oppositions to like a dual plane one versus,
01:16:36.479 --> 01:16:39.229 you know, preferring the subglandular? I don't have any.
01:16:39.439 --> 01:16:42.950 It depends on the type of the implant. So when I go for textured,
01:16:43.080 --> 01:16:47.910 and generally I go for textured anatomical siltex I go submuscular.
01:16:48.240 --> 01:16:51.479 Why? Because these are firmer devices and over time
01:16:51.479 --> 01:16:56.629 looking at my data, putting them sub downed a thin out tissue so I want that extra coverage.
01:16:57.120 --> 01:16:59.950 On top of that rippling issue with the CPG.
01:17:00.680 --> 01:17:05.549 However, with the smooth device, the ergo 2, that's where I'm doing the shift with smooth.
01:17:05.729 --> 01:17:07.149 I go subglandular.
01:17:07.439 --> 01:17:10.759 Why? Because with the lesser implant I'm able to get
01:17:11.120 --> 01:17:14.310 more projection. I have a small scar, faster recovery,
01:17:14.759 --> 01:17:19.680 and, and so based on the type of device, patient constitution,
01:17:20.000 --> 01:17:22.799 patient selection, I picked the right implant for the right patient.
01:17:25.770 --> 01:17:29.310 Mhm. So in the few minutes we have left, I think
01:17:29.310 --> 01:17:35.140 since the this the section is titled Changing trends in breast augmentation,
01:17:35.589 --> 01:17:40.799 I would just query each of the panellists and ask them what either,
01:17:41.069 --> 01:17:47.430 what has changed in the last few years in your practise that you used to do that you no longer
01:17:47.430 --> 01:17:48.990 do or.
01:17:49.540 --> 01:17:56.359 What do you see as a problem that you haven't found yet a solution to that you think in the
01:17:56.359 --> 01:17:59.919 future? So some a bit of a retrospective into the past
01:17:59.919 --> 01:18:04.620 to see what you've changed or a prospective into the future to say,
01:18:04.640 --> 01:18:10.080 you know, this is a kind of compelling clinical issue or conundrum that I haven't fixed,
01:18:10.120 --> 01:18:11.950 so maybe start with Konstantine.
01:18:12.660 --> 01:18:17.089 Well, you said in a few words talking about what has changed in my practise,
01:18:17.100 --> 01:18:18.290 it's changed a lot.
01:18:18.580 --> 01:18:22.089 Every single day we have a challenge after this meeting going back home,
01:18:22.229 --> 01:18:25.629 I will start to use motivine implants, probably no, I'm joking,
01:18:25.899 --> 01:18:30.220 but going back to what you said, never say never, never,
01:18:30.529 --> 01:18:37.140 yes, that was now the next OK I was a problem you haven't fixed the
01:18:37.140 --> 01:18:39.180 consistency of the Purina.
01:18:39.879 --> 01:18:43.910 When you are going to fix a pseudoptotic or optotic breast,
01:18:44.479 --> 01:18:49.200 we can change the skin. We can change by reducing we can change the
01:18:49.200 --> 01:18:54.410 posterior wall of the glandular poinyma by scoring or coagulation or internal future,
01:18:54.520 --> 01:19:00.419 but inside the poinya and that we have more and more with stable implants,
01:19:00.439 --> 01:19:04.609 more waterfall deformity sometimes that's why a. Founding plants,
01:19:04.620 --> 01:19:09.620 it's much more forgiving. That is the thing I'm still looking how to
01:19:09.620 --> 01:19:14.459 change that that's interesting you say that so we think about frontiers anatomic frontiers
01:19:14.459 --> 01:19:19.410 we've dealt with incision choices placement relative to the pec muscle,
01:19:19.620 --> 01:19:24.379 but what about the interface between the parenchyma and the muscle itself and you've
01:19:24.379 --> 01:19:27.540 already started doing some of these kind of horizontal.
01:19:28.120 --> 01:19:30.890 with the tubers that's why I changed the dual plane.
01:19:31.040 --> 01:19:36.080 I try to keep the muscle. It's an intermediate structure and indifferent
01:19:36.080 --> 01:19:39.990 of the muscle contraction because I don't like the contraction,
01:19:40.200 --> 01:19:46.029 but then I did this, uh, keyhole dissection between the muscle and the glandularinyma where
01:19:46.029 --> 01:19:50.879 you can do whatever you want. It's a full plane of experience where you can
01:19:50.879 --> 01:19:54.500 do scoring. Coagulation penetration with the endo
01:19:54.500 --> 01:19:59.819 coagulation into the porricua and sometimes removing some porriya in as as asymmetrical
01:19:59.819 --> 01:20:03.299 breast. Remember, remove the chasseniak's pet fat layer
01:20:03.299 --> 01:20:10.100 which is create like a gliding place with risk of waterfall deformity there use a full
01:20:10.100 --> 01:20:13.930 imagination techniques and a lot of a lot, a lot of things,
01:20:14.459 --> 01:20:15.700 um, Mark, you wanna.
01:20:16.830 --> 01:20:23.529 I mean, the time has changed and as you said, the ALCR has stopped a lot of us using texture
01:20:23.529 --> 01:20:28.540 implants in majority it's slightly uh uh to avoiding.
01:20:28.609 --> 01:20:34.250 I think I had a talk with Patrick previously about the love of form stable implant and the
01:20:34.250 --> 01:20:37.529 form unstable implant. He's more into the polyurethane.
01:20:37.609 --> 01:20:39.430 I'm, I'm more into something.
01:20:39.930 --> 01:20:46.120 That is more fluid because my belief is that well OK you probably had a greater result at
01:20:46.120 --> 01:20:49.990 the beginning, but 9 months, 2 years later when the patient's age,
01:20:50.240 --> 01:20:54.629 the body, the breast changes if you have a more formstable implant,
01:20:54.680 --> 01:21:00.240 the tissue changes how what's the best way to anticipate I think this is still a question
01:21:00.240 --> 01:21:05.720 that I'm searching for and trying to figure out what exactly is best without adding on extra
01:21:05.720 --> 01:21:09.950 thing, but I think. there is a great element that the combination
01:21:09.950 --> 01:21:15.430 of uh fat transfer on top of implant is probably the best way to go forward.
01:21:16.359 --> 01:21:19.040 That's my personal opinion, Claudio.
01:21:20.720 --> 01:21:27.009 Well, yes, so, well, I'm not in front of these monsters of uh champions of breast
01:21:27.009 --> 01:21:31.799 implants. I don't do too many breast implant that's,
01:21:31.810 --> 01:21:38.450 uh, I, I, I think, uh, what Stan said the hybrid changed a lot our philosophy at
01:21:38.450 --> 01:21:39.970 home, um.
01:21:40.700 --> 01:21:47.049 I, I'm afraid of saying this because there is only one provider of polyurethane in
01:21:47.049 --> 01:21:53.890 Argentina, but I use polyurethane a lot and uh I guess I have
01:21:53.890 --> 01:22:00.879 my doubts about texture implants because, uh, not polyurethane texture because,
01:22:00.979 --> 01:22:07.620 uh, I had a chance to remove a lot of them, not only mine for different reasons.
01:22:08.160 --> 01:22:14.979 And the majority of them, they have fluid, so I always wonder what is the reason
01:22:14.979 --> 01:22:19.569 to put uh the texture because I'm, I'm not saying 10%,
01:22:19.819 --> 01:22:26.450 maybe 80-90%, just a fluid lamina is floating it's not adhering
01:22:26.450 --> 01:22:30.020 so uh that's why I am, you know.
01:22:30.680 --> 01:22:35.109 Just reluctant to use uh so your your question is yes,
01:22:36.520 --> 01:22:42.109 I was, I'm not speaking about this nano texture. I'm, I'm talking about micro the,
01:22:42.120 --> 01:22:48.160 the brand names that all we know and it's very, very common and even if at least at home in
01:22:48.160 --> 01:22:53.770 Argentina, if you take uh ecography and they always come back as fluid,
01:22:54.319 --> 01:22:57.890 uh, less than 1 millimetre 1 millimetre laminar fluid.
01:22:58.520 --> 01:23:00.890 In echography. So that's.
01:23:01.850 --> 01:23:07.720 That's why I or smooth or put everything, but I'm not a referral.
01:23:08.009 --> 01:23:14.720 My my numbers are too low and the other thing is at home patients complain about the
01:23:14.720 --> 01:23:19.169 sensitivity. They, they, it was quite common come back and
01:23:19.169 --> 01:23:24.049 say, oh, I feel, I feel good and that's since we are doing this,
01:23:24.609 --> 01:23:31.200 you know, just a little lateral to preserve we avoid that complications.
01:23:31.750 --> 01:23:33.810 For in our point of view.
01:23:34.890 --> 01:23:39.200 So Charles, you've you're obviously a master at the peak of his craft.
01:23:39.250 --> 01:23:44.850 So, but what if there's one thing in your practise that you feel still bothers you that
01:23:44.850 --> 01:23:50.490 you don't have a complete solution for that you would project into the future and hopefully
01:23:50.490 --> 01:23:53.720 find uh a better partial solution, what would that be?
01:23:53.890 --> 01:23:58.439 rupture rates rupture, yeah, rupture rates on implants.
01:23:58.529 --> 01:23:59.850 I don't know those numbers.
01:24:00.899 --> 01:24:07.390 Regardless of if I use textured or smooth, um, I think the issues I have within my
01:24:07.390 --> 01:24:09.089 practise are fairly small.
01:24:10.339 --> 01:24:15.100 Maybe it's because the way I select my patients, sometimes the best surgery is the one I don't
01:24:15.100 --> 01:24:19.009 perform. You know, he is really patient selection.
01:24:19.899 --> 01:24:26.259 Where do I predict the future, having built a practise on on textured anatomical implants for
01:24:26.259 --> 01:24:30.939 close to 30 years, however, making a slow shift for the last 8 years.
01:24:32.470 --> 01:24:35.299 Hearing what Claudio said, I've seen the same thing, fluid,
01:24:35.310 --> 01:24:38.939 etc. getting my hands on what I think is by far the
01:24:38.939 --> 01:24:44.890 most biocompatible device and therefore logically as a doctor wanting to make least
01:24:44.890 --> 01:24:51.580 harm in combination being able to do the transition to sub glandular with smaller
01:24:51.580 --> 01:24:58.220 scars combine it with what I think is the future axillary approach to be very honest in
01:24:58.220 --> 01:25:00.779 combination with high definition lipo sculpturing.
01:25:01.370 --> 01:25:07.830 I believe we'll learn more and more about how to harvest and preserve and do the fat transfer.
01:25:08.069 --> 01:25:14.620 I think that's where we'll see the future. So you're seeing a move towards axillary with
01:25:14.830 --> 01:25:16.709 a different type of texture.
01:25:17.259 --> 01:25:22.410 Uh, and subglandular, well, it's not a texture nano is just to differentiate it from regular
01:25:22.410 --> 01:25:25.930 smooth devices. It is a super smooth implant,
01:25:26.180 --> 01:25:33.100 but due to the design, it, it, it doesn't create the same type of inflammatory
01:25:33.100 --> 01:25:40.020 or even um attraction to biofilm contamination. That's why we are all taught that
01:25:40.020 --> 01:25:44.009 we can't put smooth implants of glandular we'll have capsic contractures.
01:25:44.299 --> 01:25:46.979 That is not reality with these devices.
01:25:47.490 --> 01:25:53.839 So for me not having to cut a muscle to cause that trauma is of course a better choice
01:25:54.330 --> 01:25:58.299 logically. Uh, if I could have, you know, if,
01:25:58.310 --> 01:26:04.669 if we, when you follow your patients over time, they change their lifestyle and women today do
01:26:04.669 --> 01:26:09.569 a lot of exercises, etc. so I think it's a logical way to move forward
01:26:09.569 --> 01:26:13.209 and if we can combine this doing this under local anaesthesia,
01:26:13.250 --> 01:26:16.399 which is even less harm, that's where I see the future.
01:26:16.890 --> 01:26:20.020 Are you doing local anaesthesia breast augmentation of Charles?
01:26:20.129 --> 01:26:23.430 Yes, I am. Do you have a special technique because this is
01:26:23.430 --> 01:26:30.149 really for me the past one of Patrick the same yeah no one of them is obviously to buffer the
01:26:30.149 --> 01:26:35.189 solution but also the, the pain really is when you inject it and,
01:26:35.250 --> 01:26:40.299 and if you do it under a sort of a very light sedation during the injection,
01:26:40.419 --> 01:26:41.910 the rest of the procedure.
01:26:42.359 --> 01:26:48.740 No, we do, we do noses, we do liposuctions. So why shouldn't we be able this is a
01:26:48.740 --> 01:26:52.620 subglandular, so it, it's, it's not that complicated.
01:26:52.700 --> 01:26:54.759 It's just thinking outside the box.
01:26:55.180 --> 01:27:00.459 So the future causing less trauma to the patients, less pain over time.
01:27:01.209 --> 01:27:06.080 Less affection on the tissue thinning out the tissue, following the tissue,
01:27:06.160 --> 01:27:12.080 I think is the future with smaller implants and most likely also in thinner patients high
01:27:12.080 --> 01:27:15.229 definition lapo sculpturing because they don't want to just be thin.
01:27:15.520 --> 01:27:18.470 I have these clients they want to look like they're ripped.
01:27:19.049 --> 01:27:21.680 They wouldn't look like they're in the gym 8 hours a day.
01:27:21.890 --> 01:27:26.609 They want to wear this, and you can actually do that pretty good if you've got the knowledge
01:27:26.609 --> 01:27:27.879 and the right devices.
01:27:28.089 --> 01:27:34.919 So speaking of ripped, uh, Pat, um, can you tell us how what you foresee in the future that
01:27:35.330 --> 01:27:39.609 let's say you, you haven't quite gotten a solution to?
01:27:40.520 --> 01:27:43.149 Or what would you like to see maybe? I mean.
01:27:44.379 --> 01:27:48.540 It's nice that we have, uh, you know, the confusing thing is that we have such different
01:27:48.540 --> 01:27:51.680 opinions because, um, and, and it's very difficult to say who's right,
01:27:51.700 --> 01:27:54.379 who's wrong. I'm the complete opposite to Charles,
01:27:54.540 --> 01:27:56.660 so I've gone more and more textured.
01:27:57.100 --> 01:28:02.029 The thing that's changed in my practise is really the advent of polyurethane in the last
01:28:02.029 --> 01:28:06.939 6-7 years, which has been a great discovery for me, um,
01:28:07.379 --> 01:28:11.569 and the maintenance of the shaped implant, uh, which again,
01:28:11.950 --> 01:28:13.580 I feel uh.
01:28:14.089 --> 01:28:17.830 In general, not always, but in general gives a a a better outcome.
01:28:17.870 --> 01:28:20.160 So that's been a big game changer for me.
01:28:20.549 --> 01:28:25.379 I think the other thing that's changed is I'm not as obsessed with the dual plane as I was,
01:28:25.790 --> 01:28:29.689 um, I think, um, and again just to be a little bit controversial,
01:28:29.990 --> 01:28:34.470 sitting on this panel, John Tibbetts did many good things for the um specialty,
01:28:34.509 --> 01:28:38.529 but he did make us all obsessed with the dual plane, a bit too obsessed with it.
01:28:39.020 --> 01:28:42.069 What do you mean by that? Well, I, I think that too many people have dual
01:28:42.069 --> 01:28:46.430 plane that don't need it. Um, and so, um, and there are consequences of,
01:28:46.490 --> 01:28:51.750 of, of, of dual plane procedures, so one thing I do agree with Charles with is that when I can
01:28:51.750 --> 01:28:55.700 go sub fascially or above the muscle, I will do that.
01:28:56.229 --> 01:29:01.620 So, so probably I'm 50/50 dual plane, um, uh, subfascial, um,
01:29:01.629 --> 01:29:03.020 so that's been a big change.
01:29:03.270 --> 01:29:07.640 And the other big change has been the use of sedation for all of my primary breast,
01:29:07.750 --> 01:29:09.540 um, uh, surgery.
01:29:09.990 --> 01:29:12.799 Uh, that's been a huge difference in terms of recovery.
01:29:13.430 --> 01:29:16.990 Um, in terms of what I see in the future, I, I think, you know,
01:29:17.069 --> 01:29:21.299 we all sit here and say many times, there is no such thing as the perfect implant,
01:29:21.390 --> 01:29:26.459 and there isn't, um, and they've all got advantages and disadvantages.
01:29:26.950 --> 01:29:32.990 Um, for me at the moment, my, my, my flavour of choice is the anatomical polyurethane.
01:29:34.080 --> 01:29:41.080 I do have some issues with edge visibility and some of those um but uh and if if I could
01:29:41.200 --> 01:29:44.379 get rid of that and improve upon that I'd I'd be a happy man,
01:29:44.520 --> 01:29:50.319 uh, super happy man, but, uh, yeah, but Mark, I have a question for you how do you manage
01:29:50.319 --> 01:29:56.759 psychologically your Asian patient coming asking for a short scar but with big
01:29:56.759 --> 01:29:58.759 tattoos on the body.
01:29:59.770 --> 01:30:01.930 Well, I think a lot of them I just try to avoid it.
01:30:02.009 --> 01:30:05.430 I just say it's, it's pretty simple. I mean, I usually say,
01:30:05.529 --> 01:30:06.950 look, this is your shoulder frame.
01:30:07.709 --> 01:30:13.540 I can make you quite large, technically, but the issue is that you got to look at the
01:30:13.540 --> 01:30:17.970 electoral profile. So I think one of the speakers talking about
01:30:17.970 --> 01:30:21.000 the whole full length mirror, I think that's just the vital part of it.
01:30:21.009 --> 01:30:24.620 I just said look, You got to have a frontal and posterior balance.
01:30:24.830 --> 01:30:29.910 If you don't have a lot of buttock, there's no point being too top heavy and usually they then
01:30:29.910 --> 01:30:33.799 they all can visualise because all they want to look is look from top,
01:30:34.069 --> 01:30:37.899 but they never really look at the sideway and say actually I cannot carry that much.
01:30:38.770 --> 01:30:43.589 Yeah, I think actually we're getting the hook from the uh puppet masters.
01:30:43.750 --> 01:30:48.430 So uh thank you everybody. That was a wonderful session and we'll directly.
01:30:53.339 --> 01:30:53.729 Hey.
01:31:13.100 --> 01:31:16.899 Yeah, I have one. Farhadi.
01:31:21.600 --> 01:31:26.729 It No, this one.
01:31:30.399 --> 01:31:35.169 Yeah. But
01:31:46.140 --> 01:31:47.140 Thank you.
01:31:59.109 --> 01:32:04.049 Put on a. Oh, OK. No.
01:32:18.729 --> 01:32:21.810 OK, here it is. So I and I, we're flanking you guys,
01:32:21.899 --> 01:32:23.589 OK, just so you know.
01:32:24.779 --> 01:32:29.040 So the idea is John.
01:32:32.200 --> 01:32:37.149 A bit discussed about this, you know, caps the contraction, especially when we didn't sit with
01:32:37.149 --> 01:32:41.830 the patient. Do we say, oh yes, you know, this if this.
01:32:42.540 --> 01:32:46.540 This colleague of mine who has used that implant, if he would have used a different
01:32:46.540 --> 01:32:51.740 implant, then you would have never got the capsule contraction or if it's your own
01:32:51.740 --> 01:32:55.910 patients. I'm so sorry, but you know, you must have
01:32:55.910 --> 01:32:59.620 something genetic that you have developed this capsule contraction because in my hands,
01:32:59.870 --> 01:33:01.549 I never get capsule contraction.
01:33:03.680 --> 01:33:05.310 Or do we just blame each other.
01:33:06.689 --> 01:33:10.270 And it's, you know, well, you know, if you use antibiotics for this washout,
01:33:10.359 --> 01:33:12.000 you know, what's the purpose of that?
01:33:13.200 --> 01:33:16.910 I think what we need, what we see, it's very confusing.
01:33:17.569 --> 01:33:23.089 And I think the idea of this discussion is a bit to see who really to blame to,
01:33:23.169 --> 01:33:27.379 or is it really at the end, only the surgeon to blame, and it doesn't matter which implant we
01:33:27.379 --> 01:33:31.069 used. The outcome could be still the same if you
01:33:31.069 --> 01:33:32.430 choose the right technique.
01:33:34.459 --> 01:33:36.209 So, I start with you.
01:33:38.270 --> 01:33:40.470 Well it's got to be someone else's fault yeah.
01:33:41.689 --> 01:33:48.140 Um I think you know, I think most of us would say that whatever implant you're
01:33:48.140 --> 01:33:51.729 using, capture contractor rates happen to all of us,
01:33:52.180 --> 01:33:54.410 but certainly not as much as they did do.
01:33:54.899 --> 01:34:01.209 So I think that there is a lot related to technique
01:34:01.779 --> 01:34:06.209 and steps taken to minimise that. We know that Bill Adams has done a lot of work
01:34:06.209 --> 01:34:10.060 on contamination, the 14 point plan.
01:34:10.509 --> 01:34:16.569 Everything to minimise um that um infective stimulus to the,
01:34:16.640 --> 01:34:20.029 to the caption, I think that has made it, I think it's made us better surgeons,
01:34:20.100 --> 01:34:26.060 it's made us think more um less dramatic, cleaner, um,
01:34:26.149 --> 01:34:29.270 fewer people, more efficient, all of those things are,
01:34:29.350 --> 01:34:32.779 are, are good things. We're never going to eliminate capture
01:34:32.779 --> 01:34:36.140 contracture. Um, and I think more recently we do know that
01:34:36.140 --> 01:34:42.100 there are some surfaces like the moti implants, which definitely do seem to have much thinner
01:34:42.100 --> 01:34:47.620 capsules than other traditional smooth or textured implants.
01:34:47.740 --> 01:34:50.009 So I think it has to be a combination of both.
01:34:50.479 --> 01:34:54.979 Um, I think you've got to look at your own practise, you've got to review your own cases.
01:34:55.100 --> 01:34:57.810 Um, Charles always talks about looking at your own data,
01:34:57.899 --> 01:34:59.020 I think that's very important.
01:34:59.589 --> 01:35:05.899 And how big a problem that is in your practise and what you might do to change or address that.
01:35:06.310 --> 01:35:10.669 So I think it's a a little bit of both. I would like to think that with good surgical
01:35:10.669 --> 01:35:14.100 technique, it's not a huge problem today.
01:35:16.830 --> 01:35:22.419 I think the issue is the fact that we really don't have the data and I'm coming back to what
01:35:22.419 --> 01:35:24.979 you said yesterday afternoon.
01:35:25.379 --> 01:35:30.470 The issue with aesthetic surgery, especially not plastic surgery,
01:35:30.529 --> 01:35:37.529 but aesthetic surgery especially, is that it's very difficult to collect the data because no
01:35:37.529 --> 01:35:43.490 two surgeons have the same pair of hands, no two surgeons have the same aesthetic sense,
01:35:43.850 --> 01:35:49.930 and no two patients are the same, so it's going to be very difficult for us to standardise.
01:35:50.129 --> 01:35:54.770 Having said that, I'd like to address all three.
01:35:55.529 --> 01:36:02.279 Uh, I won't dwell too much on the surgeon because much has already been said today and
01:36:02.279 --> 01:36:04.990 Patrick has quoted the work of Bill Adams.
01:36:05.319 --> 01:36:10.080 We've all adapted to that other than to say that, you know,
01:36:10.160 --> 01:36:14.279 we're all different. Uh, there's, there's even some evidence now
01:36:14.279 --> 01:36:21.040 that you should use a different funnel for each side because you've put it on the skin on one
01:36:21.040 --> 01:36:24.479 side and then you're putting it into the other implant pocket.
01:36:24.600 --> 01:36:26.560 So yes, there's something to surgeon.
01:36:27.140 --> 01:36:29.290 I'd like to address the implant.
01:36:29.779 --> 01:36:33.580 Uh, by the way, I'm very envious of you. In the 80s,
01:36:33.660 --> 01:36:38.910 we used close to 3000 polyurethane implants at Emory, John Bostick,
01:36:39.040 --> 01:36:40.450 Rod Hester and I.
01:36:40.660 --> 01:36:44.899 It was the best implant I ever used for many reasons.
01:36:44.939 --> 01:36:48.609 A, it was the first shaped implant I could ever use.
01:36:49.180 --> 01:36:53.089 B on capsular contracture rate went down.
01:36:53.770 --> 01:36:57.049 So yes, the implant does play a role.
01:36:57.580 --> 01:37:04.500 Yes, the polyurethane, uh there's no question that it there's less capsular contracture with
01:37:04.500 --> 01:37:05.770 polyurethane.
01:37:06.020 --> 01:37:09.379 I think the evidence with the micro textured.
01:37:10.629 --> 01:37:15.350 Motiva is coming in. It's early days yet, uh,
01:37:15.379 --> 01:37:21.250 with what 4 year follow up to tell that it's significantly going to be lower,
01:37:21.259 --> 01:37:26.209 but it's promising. So that's the device and number 3 is the
01:37:26.209 --> 01:37:33.100 patient, uh, we know that smokers tend to have more capsular contracture if we're
01:37:33.100 --> 01:37:38.209 talking about reconstruction as well as uh aesthetic breast surgery.
01:37:39.020 --> 01:37:43.729 We know those who've had radiation are at greater risk and.
01:37:44.509 --> 01:37:51.310 Anyone with a thin habits, it isn't that they get less capsular contracture,
01:37:51.350 --> 01:37:57.620 it's just that it's much more evident and then we come to this whole thing of uh
01:37:57.910 --> 01:38:04.759 patient compliance uh if I put my patients on Singulair,
01:38:04.910 --> 01:38:10.149 are they going to take it regularly if we believe in.
01:38:10.669 --> 01:38:17.209 Massage the breast and moving the implant around, do they do it routinely so.
01:38:18.250 --> 01:38:23.180 I think it's, I think it's all 3, but as Patrick said,
01:38:23.419 --> 01:38:29.180 the patient will always blame the doctor, the manufacturer will always blame the doctor and
01:38:29.180 --> 01:38:34.229 say our devices are perfect, it's the way you handling it and.
01:38:36.250 --> 01:38:39.200 And we take the responsibility as we should.
01:38:42.049 --> 01:38:44.060 So I think um.
01:38:45.089 --> 01:38:48.899 You know, capsular contracture, if you just think about it.
01:38:50.040 --> 01:38:55.350 Uh, simplistically and maybe logically, it's an end product of inflammation,
01:38:55.520 --> 01:39:00.959 so it's a fibrosis that comes from inflammation and the way I think of that is that there's two
01:39:00.959 --> 01:39:05.609 main sources of that inflammation in the breast. So number one,
01:39:05.620 --> 01:39:11.040 we all know is infection. So minimising infection um is a way to minimise
01:39:11.040 --> 01:39:12.120 capsular contracture.
01:39:12.759 --> 01:39:19.399 Um, but number 2 is, is bleeding. So Doctor Flowers did a study back in the uh
01:39:19.399 --> 01:39:26.319 80s, I think, where he um showed that even one CC and this was
01:39:26.319 --> 01:39:31.879 in an animal model, but even one CC of blood was sufficient to create fairly intense and
01:39:31.879 --> 01:39:37.200 clinically visible capsular contracture so uh in terms of what I try to do,
01:39:37.209 --> 01:39:40.479 if those are the two main sources of inflammation.
01:39:40.759 --> 01:39:43.790 Uh, I try to minimise the risk for infection.
01:39:44.129 --> 01:39:50.009 Um, I'm not as crazy about minimising contamination, which I,
01:39:50.129 --> 01:39:52.290 I think is very different from infection.
01:39:52.740 --> 01:39:58.379 Um, but to the extent that I wanna keep things sterile so that contamination does not then,
01:39:58.629 --> 01:40:03.700 uh, escalate or cascade into, um, infection, I'll do that,
01:40:03.990 --> 01:40:08.100 but with bleeding that's something I think is a is a big source,
01:40:08.270 --> 01:40:11.939 um, subclinical bleeding as well as acute. So, um,
01:40:12.430 --> 01:40:17.439 if I'm doing a sub glandular approach, I, I mean hemostasis is exquisite.
01:40:17.509 --> 01:40:21.589 I might spend fully half of my entire OR time.
01:40:21.970 --> 01:40:25.930 Uh, trying to get hemostasis and the other thing that I,
01:40:26.089 --> 01:40:30.770 uh, you know, I don't see a lot of capsular contracture probably because of a lot of the
01:40:30.770 --> 01:40:36.529 things that we've already learned over the years and done but one thing I don't do is I
01:40:36.529 --> 01:40:39.970 don't have my patients massage their breasts at all early on.
01:40:40.399 --> 01:40:45.120 Um, early on I think you still have this raw open surfaces,
01:40:45.410 --> 01:40:51.250 and I think all the massaging that they do could potentially stir up subclinical bleeding
01:40:51.250 --> 01:40:55.200 that can create potentially issues down the road, uh,
01:40:55.209 --> 01:40:59.450 after a period of 1 to 2 weeks when I've gotten some consolidation.
01:40:59.564 --> 01:41:04.995 The shape and we know that those uh friable vessels have sealed then I'll do some gentle
01:41:04.995 --> 01:41:11.475 massage afterwards um I do use Singulair again because it's an anti-inflammatory and
01:41:11.475 --> 01:41:18.115 inflammation is the uh downs or the upstream um trigger for a capsular
01:41:18.115 --> 01:41:21.359 contracture. Um, and, and I think in terms of,
01:41:21.540 --> 01:41:24.819 so that's patient, so with patients, I, I make sure that they,
01:41:24.939 --> 01:41:31.259 they're not active, they're not massaging, so like I don't do this 24 hour kind of flash
01:41:31.259 --> 01:41:35.740 recovery exercise that I, I know is in vogue. I tell them you gotta let your blood vessels
01:41:35.740 --> 01:41:40.020 seal and heal so they can't do anything but walking for for a couple of.
01:41:40.169 --> 01:41:46.319 Weeks um and then surgeon things surgeon factors of course minimising contamination now
01:41:46.319 --> 01:41:52.759 device factors I think this is where there's a lot of variability um because I think that
01:41:52.759 --> 01:41:59.029 there's certain devices that are more prone to that inflammation so saline implants,
01:41:59.040 --> 01:42:01.240 you know, I think with the water hammer effect.
01:42:01.879 --> 01:42:08.350 You're getting a kind of almost a myoelastic kind of constant water hammer effect on
01:42:08.350 --> 01:42:12.680 the surrounding capsule and that I think that that can stimulate capsular contracture.
01:42:13.129 --> 01:42:18.910 Um, and I also agree with what Doctor Nahaa just said is that no matter what the aetiology
01:42:18.910 --> 01:42:23.700 patient driven device driven or or surgeon malfeasance, ultimately,
01:42:24.069 --> 01:42:29.859 uh, it's a problem and if if that we're responsible for it and patients will always
01:42:29.859 --> 01:42:36.830 expect you to fix that capsular contracture so I think the best um thing that we can do is
01:42:36.830 --> 01:42:42.069 take all of these multifactorial sources and control them as much as possible.
01:42:43.370 --> 01:42:44.819 I have the mic thank you.
01:42:45.229 --> 01:42:52.220 So, uh, step by step I think today CASA contractor should not be an
01:42:52.220 --> 01:42:55.149 issue. Regardless of what implant we're using,
01:42:55.560 --> 01:42:59.589 looking at my numbers, my data, getting back to the lecture I had yesterday.
01:43:00.689 --> 01:43:05.740 And that's why I encourage everyone to get their own data because your patient population,
01:43:05.830 --> 01:43:11.770 your patient population behaviour, your septic environment, your surgical environment,
01:43:11.830 --> 01:43:15.830 your technique decides where your numbers will be.
01:43:16.810 --> 01:43:20.240 So looking at my numbers, regardless of what implants I've been using,
01:43:20.649 --> 01:43:26.359 the caps contractual rate is fairly low, and that's not because so I know what it is.
01:43:26.529 --> 01:43:33.250 So the six year study on the motiva showed 0.4%, but those were combined secondary and
01:43:33.250 --> 01:43:34.640 primary in primaries.
01:43:34.930 --> 01:43:37.240 I've not had one case in 6 years.
01:43:38.529 --> 01:43:41.890 So that's uh primary cases 300.
01:43:42.939 --> 01:43:47.540 With Celtics, I've been using Ciltex since 2005.
01:43:48.649 --> 01:43:52.009 And my capsa contraction rate is 1.4.
01:43:52.390 --> 01:43:53.629 That's a very low number.
01:43:54.529 --> 01:43:58.029 And so and with polyurethane I also use polyurethane.
01:43:58.470 --> 01:43:59.950 I've not had one capsa contraction.
01:44:01.109 --> 01:44:05.540 So, so I don't believe from uh from an industrial perspective,
01:44:05.669 --> 01:44:08.859 the devices we're using them, if we use them in the right way,
01:44:09.029 --> 01:44:10.140 they're all very safe.
01:44:11.520 --> 01:44:15.580 I don't use any antibiotics with nano smooth. I don't,
01:44:15.620 --> 01:44:17.330 I don't see a necessity for it.
01:44:17.580 --> 01:44:19.410 I think antibiotics can be harmful.
01:44:20.350 --> 01:44:24.680 However, I do use it with the siltex with the textured and,
01:44:24.709 --> 01:44:26.419 and, and uh I've always done that.
01:44:27.439 --> 01:44:33.750 Regarding uh patients, I do believe patients play a role through their behaviour.
01:44:34.279 --> 01:44:36.979 We do know at least in my practise I've seen, you know,
01:44:37.160 --> 01:44:40.189 when they started breastfeeding suddenly started getting capsic contracture.
01:44:40.470 --> 01:44:46.080 So somehow there's something happening in the breast which I've also seen patients that have
01:44:46.080 --> 01:44:48.189 had problems with general infections.
01:44:48.479 --> 01:44:51.350 They get firm breasts, so they do play a role.
01:44:51.680 --> 01:44:55.029 I do believe that their behaviour post op is imperative.
01:44:56.240 --> 01:44:59.770 John mentioned that the blood thing. I absolutely agree.
01:44:59.779 --> 01:45:05.750 I give my patients 2 grammes of transamic acid 2 hours prior to surgery because of that,
01:45:05.790 --> 01:45:06.959 and that's something I learned.
01:45:07.859 --> 01:45:11.700 18 years ago in Asia, seeing how they were oozing because they were eating different types
01:45:11.700 --> 01:45:14.870 of food with the vitamins, etc. etc.
01:45:15.100 --> 01:45:19.100 which caused more bleedings, so I incorporated that with my facility.
01:45:19.180 --> 01:45:23.770 So I do believe blood is crucial and that brings us to the surgeon's responsibility.
01:45:24.500 --> 01:45:29.250 I believe that bloodless surgery is a very powerful key to this.
01:45:29.620 --> 01:45:31.229 Bacteria feed off blood.
01:45:31.580 --> 01:45:34.620 They love blood. If they don't have nutrition,
01:45:34.790 --> 01:45:36.310 there isn't a lot to survive on.
01:45:37.209 --> 01:45:40.140 So, so bleeding, I do believe plays a role.
01:45:40.390 --> 01:45:44.310 Trauma in general plays a role as septic environment.
01:45:45.129 --> 01:45:48.970 Where you choose to follow all the principles in the 14 point plan,
01:45:49.259 --> 01:45:52.390 those are very logical in their steps.
01:45:52.779 --> 01:45:59.100 So creating an environment, uh, uh, uh, for your surgery facility plays a big role and then
01:45:59.100 --> 01:46:03.939 you as a surgeon. If you decide to perform a surgery 90 minutes
01:46:03.939 --> 01:46:06.740 instead of 20 minutes, of course it has an impact.
01:46:06.990 --> 01:46:09.939 You have an open wound. There's so much science behind that.
01:46:10.109 --> 01:46:13.899 If you decide to have your implant on the table lying free,
01:46:14.109 --> 01:46:15.620 of course it has an impact.
01:46:15.959 --> 01:46:18.830 So you need to think logically how you're doing this procedure.
01:46:19.660 --> 01:46:23.330 Now even maybe static electricity opening the box has an impact.
01:46:23.500 --> 01:46:26.689 There are not any conclusive studies, but there is static electricity,
01:46:26.899 --> 01:46:30.009 so small things like this make a difference.
01:46:30.640 --> 01:46:34.129 Small matters, small things matter, and when you add them up,
01:46:34.379 --> 01:46:36.250 that's the number you'll get.
01:46:36.899 --> 01:46:41.500 So look at the details. The devil the the the devil lies in the details.
01:46:41.580 --> 01:46:44.629 So look at the details and if you're able to incorporate that,
01:46:44.740 --> 01:46:50.140 you'll be fine. Before, just before we're gonna go to the to
01:46:50.140 --> 01:46:53.660 the to the break. Because we need to be overrunning.
01:46:55.410 --> 01:46:57.279 One quick question to all of you.
01:46:58.549 --> 01:47:02.040 Do you think size matters in regard to capsule contractions?
01:47:02.129 --> 01:47:06.250 So if you would do all your good surgical technique.
01:47:08.140 --> 01:47:13.089 But the size would be a certain, you know, doesn't make a difference if you put a 200
01:47:13.089 --> 01:47:15.799 implant size implant in or a 500.
01:47:17.100 --> 01:47:20.109 What do you think? Well, I'm gonna answer two things.
01:47:20.470 --> 01:47:25.750 First of all, there is some data that suggests above 350 caps the contractual rates go up.
01:47:25.790 --> 01:47:27.750 I think that's already been published, um.
01:47:28.509 --> 01:47:30.899 Not sure whether that was Steve Titelbaum or I can't remember,
01:47:30.990 --> 01:47:36.140 but I think there is some data, um, but I just completely changed the subject.
01:47:36.470 --> 01:47:42.899 I think. Size or oversize is a much greater problem than
01:47:42.899 --> 01:47:49.029 capsular contracture. I think the size of the pocket
01:47:49.029 --> 01:47:54.149 matters, and I know that when we were using the textured implants,
01:47:54.549 --> 01:48:00.939 everybody said make it exactly the size of the implant, otherwise the implant will turn on you,
01:48:01.390 --> 01:48:03.140 but I think with the.
01:48:04.049 --> 01:48:09.890 Around implants, if you put a round implant into a tight pocket where the.
01:48:10.750 --> 01:48:15.430 Diameters are different, you've already started with capsular contractures,
01:48:15.470 --> 01:48:22.259 so I think the size of the pocket should be commensurate with the dimensions of the implant.
01:48:23.609 --> 01:48:30.490 I I think uh we know that you know in different other body systems that uh
01:48:30.490 --> 01:48:36.569 inducing stretch can induce a kind of a uh contrarian uh
01:48:36.569 --> 01:48:43.279 fibrotic response so I think the size of the pocket relative to the device has to be
01:48:43.279 --> 01:48:46.479 fairly well matched. I think if you get too big.
01:48:47.020 --> 01:48:51.049 Um, and, and the, and the pocket can't sustain it.
01:48:51.089 --> 01:48:54.689 I think that puts pressure if there's, if they're too small,
01:48:54.939 --> 01:48:58.899 then I think you get this water hammer effect so I think it's a balance,
01:48:59.180 --> 01:49:02.810 uh, a hand in glove, reasonable hand in glove fit.
01:49:05.339 --> 01:49:10.240 But, but I wanna say going back to again to uh Charles and,
01:49:10.250 --> 01:49:16.529 and Doctor Nahai's 0.1 of the problems, one of the reasons why we have this mythos around
01:49:16.529 --> 01:49:22.890 capsular contracture is because it's become so rare when you have something that only happens
01:49:22.890 --> 01:49:24.569 1 or 2% of the time.
01:49:25.020 --> 01:49:31.899 Then the problem is you don't have in your own internal uh kind of gestalt a way of
01:49:31.899 --> 01:49:37.779 figuring out well this happened to me last year so what did I do or or remembering anything
01:49:37.779 --> 01:49:42.779 about it if this were happening like at 10 or 20% like it used to happen,
01:49:42.870 --> 01:49:47.500 I think we we would be able to get more traction and granularity but right now it's
01:49:47.500 --> 01:49:51.459 happening so rarely we don't know and I think in many ways some of the little things that
01:49:51.459 --> 01:49:55.495 we're doing. Probably out of 20 things 19 don't make sense,
01:49:55.754 --> 01:49:59.865 but we're doing it because we don't want it we don't want anything to change but we don't know
01:49:59.865 --> 01:50:04.875 which of those 20 things that we're doing is actually maybe the most important thing and as
01:50:04.875 --> 01:50:10.314 Charles said maybe it's all of them but I I I tend to think that this is a problem of data
01:50:10.314 --> 01:50:15.314 that we don't really think about it and for instance like when Casler contractor happens
01:50:15.314 --> 01:50:19.265 who's who in the audience is recording when it when it happened.
01:50:19.529 --> 01:50:24.189 And going back retrospectively and trying to figure out did I get subclinical bleeding there?
01:50:24.359 --> 01:50:29.720 Did she have a dental tooth extraction or did she report a cold two weeks afterwards we're
01:50:29.720 --> 01:50:35.200 really not doing that and it's because it's a data problem it's so rare and it's
01:50:35.200 --> 01:50:38.629 retrospective when we find out about it, everything's already happened,
01:50:38.680 --> 01:50:41.439 so we, we don't have optics into the ideology.
01:50:42.290 --> 01:50:45.009 I have two takes on this. If we believe that bleeding,
01:50:45.089 --> 01:50:49.850 bacterial contamination plays a role, if you do dissect a bigger pocket,
01:50:49.970 --> 01:50:53.490 which is obvious for a bigger implant, the chances of hitting more vessels,
01:50:53.609 --> 01:50:56.000 having more bleedings, theoretically are bigger.
01:50:56.450 --> 01:50:59.600 You also take more time and you have a more surface area,
01:50:59.970 --> 01:51:02.129 more chance for bacteria, quite logical.
01:51:03.540 --> 01:51:08.709 My dilemma with this discussion is about what is a capa contractor?
01:51:09.540 --> 01:51:14.290 How do you determine a grade 2 or a grade 3? Who determines it?
01:51:14.459 --> 01:51:16.129 The patient or the doctor?
01:51:16.640 --> 01:51:20.290 Where's the objectiveness in this? How do you follow your patients over time?
01:51:21.399 --> 01:51:24.399 And this is the thing. What is a capsic contractor?
01:51:24.589 --> 01:51:29.479 We've got this grading 1 to 4, which most of us, but really it's an objective,
01:51:30.379 --> 01:51:33.270 subjective evaluation from the doctor and the patient.
01:51:34.240 --> 01:51:38.120 I mean our practise, the philosophy is we follow our patients at least 10 years with
01:51:38.120 --> 01:51:43.600 ultrasound and we measure the capsule and then we combine that measurement with the symptoms
01:51:43.600 --> 01:51:45.009 the patients are describing.
01:51:45.439 --> 01:51:48.029 I think that's a more objective way of doing this.
01:51:48.319 --> 01:51:52.919 So there's a dilemma in this discussion really what is a capa contraction who.
01:51:53.649 --> 01:51:54.810 Says it is.
01:51:55.100 --> 01:51:58.430 I've had patients coming to me complaining I have such firm breasts.
01:51:58.500 --> 01:51:59.859 It's got nothing to do with the breast.
01:52:00.750 --> 01:52:02.439 Capsule, it's a breast implant.
01:52:03.700 --> 01:52:08.870 So, so it is a slightly complicated and the numbers we're basing this on,
01:52:09.120 --> 01:52:13.390 they're difficult to to to interpret because it's not really true science,
01:52:13.640 --> 01:52:17.040 it's opinions you know and you know it's not a good foundation.
01:52:18.259 --> 01:52:21.959 Yeah I think especially for breast reconstruction tissue,
01:52:22.330 --> 01:52:28.129 uh, I mean prosthetic reconstruction, it's a problem because oftentimes that what patients
01:52:28.129 --> 01:52:34.930 and even doctors think is a tight contractor it's just a mismatch of a large implant with a
01:52:34.930 --> 01:52:41.654 tight skin sparing pocket and I think it's it. Feels firm because it is firm but that's very
01:52:41.654 --> 01:52:48.334 different from a from a specific capsular fibrotic process that you see in a cosmetic
01:52:48.334 --> 01:52:54.015 breast case so I think capsular contracture and how it's described in prosthetic recon is a
01:52:54.015 --> 01:52:56.544 real issue. OK, thank you very much all.
01:52:57.214 --> 01:52:58.365 I think we need a coffee now.