So welcome back everyone. The next session is on tips and tricks in
aesthetic surgery.
We've got some great, uh, presentations, great speakers to look forward to,
and uh if we introduce Paolo again as our first speaker to take it away.
Thank you, Mark. And uh I want the the topic to this talk is uh
how to place the incision uh in flat chest of the breast,
basically. So these again are my disclosures and we all
know, we can do breast augmentation through different um accesses and,
um, I usually use the inframammary fold incision and that's for sure the most common
incision used for breast augmentation, probably the easiest and it's recommended for,
for beginners because it allows direct visibility on the pocket and and what we're
doing. And also, uh, it allows the possibility to
perform the dissection sharply. So you see, I,
I, you know, I. I grab the fibres and I um and I burn them and
I do what I call a pinch and swing technique so it's less pain and quicker recovery.
It's easier to control bleeding if you have a bleeder.
So I mean this technique is is what I usually use and also the insertion of the implant is
very easy. I always use um an insertion funnel and it's uh
uh. Also very easy to look at the implant,
especially for anatomical implant, when you have the marking and see where it is to make
sure the implant is placed correctly. And last but not least,
literature tells us that the risk for capsular contracture for inflamm fold is way lower than
periareolar or transaxillary.
So when it comes to deciding where to put the incision, you know,
we have a few methods actually described.
Uh, from different authors and uh you know, the bottom line to all these is how to measure
before surgery in order to make sure that we're gonna put the incision where the new
inflammatory fold is going to be because sometimes the new inflammatory fold does not
match the old inflammammary fold, so we don't have to put uh the incision in the old
inflammatory fold, for example, if we are lowering it,
because otherwise we will have the scar falling on the breast.
And this, uh, is especially true on patients that don't have an informal to start with the
so-called flat chest of patients just like you can see in these pictures.
I, my approach to this is, uh, uh, the AK method, uh,
described by Pat Dan, which was my mentor at Academic clinic in Stockton where I've been for
many, many years and usually it, it's, I, you know, I myself was when I was a fellow there I
thought it was very difficult to understand but actually.
It's, it is not difficult. You have only to think about two things,
uh, how to place, uh, the implant in relationship to the niprola complex and where
exactly how to calculate where to put the incision.
And like I said, it's very simple. I can just show you in a couple of minutes.
Uh, we all know, we, I, I spoke about this also earlier today that the implant should be placed
just so it's centred, so half of the, uh, high of the implants should be on top of the um of
the, of the nip complex and half of it below the.
Um, uh, the niperoa complex, and for this reason, we have to estimate where the nip neola
complex is going to be after the implantation and all we do is ask the patient to raise her
arms on top of the head just like this picture shows and we.
mark a line that goes from the nipple to the sternum and then it's very easy.
We have the charts and we can choose the implant height and we just have to make sure
that the implant is centred so it takes around 30 seconds to do it.
And the second important thing which comes down to uh the topic of my talk today which is
uh where are we gonna put the incision just so we make sure it's in the fold or when we have
to do a new fold because there's no fault, how are we gonna are we gonna calculate it?
Well, uh, obviously you know the where we're gonna put the incision is influenced by.
Uh, the width and projection and the volume of the implant,
how much skin we have, and all the rest.
And usually, it's a very, very easy formula. It's the LVC,
which is the lower ventral curvature of the implant, which is on the,
uh, charts of the implant, plus half of the pinch test.
Usually, if you have a patient like this one, the the pinch test can be maybe 1 centimetre.
So if we divide it by 2, you add a 0.5 centimetres to the LBC.
So in this one case, you can see there, it's very simple.
You ask the patient to put her hands on top of the head,
and then you actually measure 9.5 centimetres, which is the LBC plus of the pinch,
and that's where the new, um, inflammary fold is going to be after surgery.
In this page, she has no inflammatory fold, and we're gonna create it.
And once we have done surgery, it is for me very important to secure the inframammary fold.
You know, I've published this, uh, uh, paper a few years ago on ASJ,
uh, in which I describe what I call the four layer closure,
uh, of breast augmentation, and it takes one minute to show you this video.
It's with barbed sutures. I take very strong bites between the scarpus
fascia and the thoracic fascia down there, uh, with the first arm of this,
uh, qui. Suture. The second layer goes from the scarpus fascia
up there to the scarpus fascia down there.
And, uh, uh, well, this video is slightly, um, uh, forward.
I mean, it goes a little bit faster than than I usually am,
but still it takes no more than than literally 23 minutes to perform the closure with one,
thread. The third layer, as you can see here,
is just the dermal and it's very important to be, um.
Far from the skin edges because you don't wanna create any irritation and this is gonna give
you a bulgy appearance of the scar and you have to tell patients that the scar is gonna look
like that because it's not look, it's, it's not going to look very nice right from the
beginning and patients are gonna wonder if you're really a plastic surgeon or not.
And, and the fourth layer is a 30 monoryl. I use a straight needle,
uh, which can be very, very uncomfortable if you start,
but when you get used. It's very, very fast.
You don't have to load it on a needle holder. It goes very fast,
especially if you have to suture abdominoplasty, wounds.
It really goes very fast.
Um, and once this is done, you can see now what the suture looks like.
And like I said before, it's, it's very rigid, it's very bad looking.
It takes around 2 months before it flattens down.
And by this means, you can see how you can actually create a nice fold,
fixate it, have the scar. Fall exactly in the new inflamm fold you can
see here the patient that is completely flat no inform fold,
and we have created a fold and the scars is in there and it's invisible.
So what is the conclusion to to all this? It's a little bit of a provocation,
I know. Please don't use scisors, uh, because what I
think is we need to go uh to surgery having a plan, or at least I do so.
I choose a plan before surgery. Do you know why?
Because in a patient like this that has no um uh no no chest,
no tissue, you know, the bigger the implant now this is probably an exaggeration that you can
see there the bigger the, the, the implant is and the lower the incision is going to be.
So if I choose the first implant up there, the incision is gonna be the first line.
If I choose a bigger implant, the the incision is gonna be maybe the last line.
So if I go into surgeries and I don't know what implant I'm gonna use,
where am I gonna put the incision? How am I gonna start the operation?
How am I gonna make sure that the inframammary fold and the incision match to each other
because they are dependent.
I mean, like I said, you know, the bigger the implant, the further down the incision goes.
So we need to know what implant we are going to use if we want to make sure that uh the
um scar is gonna fall inside then your inform mamary fold and this is true especially in
patients with no uh chest to start with and that's basically all I have to say about this
topic, so thank you for listening.
Our, our next speaker, well, everybody knows him, Patrick,
thank you very much.
He's going to talk about how to mely say the nipple brace augmentation and mastopexy.
So, um, thank you very much, uh.
And, oh, let's do this, right.
Uh Thank you very much and um.
Thank you to whoever gave me this to talk about because uh this is gonna be a
fairly brief talk.
Cos I've never done it.
Um, it's called the medialization of the nipple, so yeah,
uh, I have never done it.
Um, in fact, I would say that, you know, nipple position, you know,
is an issue, but I spend most of my time just telling people,
just managing people's expectation.
If you've got breasts which naturally fall apart, that's where they're gonna remain.
Um, and I tell them that, you know, it might be more exaggerated with implants.
So I don't have a good, um, answer for you, I'm afraid.
If you've come looking for answers, you've come to the wrong place.
Um, but yeah, so, so as I said, I think, you know, the,
the only thing I always explain is that.
Uh, you know, the nipple has to be at the centre of the implants,
so if you do have lateralized nipples, um, those, those,
those implants are gonna have to stay, uh, laterally if you're naturally very close in the
middle, you stay close in the middle, and I just explained to patients,
look, it's all about rib rotation and position of the nipple on the chest wall,
and if you're rotating.
Um, if you've got a, a flat chest or slightly inwards, you'll get a cleavage.
If you point outwards, you're gonna point outwards.
So a young girl like this and say, look, you got, you got a little bit of separation,
it's not a big deal.
What you can do is you can um you know, change the profile of your implant,
you might want to use a slightly wider implant, you might preferentially go subfascial rather
than submuscular, so that you're not pushing your implants further wide.
But I'm not doing anything specifically about the nipple,
as I said, you see these two people, they've got very different um chest wall rotations
where. You know, one's never gonna look like the other,
um, and so really it is just about er er you know, managing that expectation.
I think with a mastopexy as well, and women will often do this and say,
oh yeah, I, I, I, I want to lift a little, I want to lift,
and I go, no, no, no, you're not gonna get that. I said I,
I can lift you in the direction in which your breasts lie,
but I can't, you know, I can't, I can't do this to you.
Um, however, by virtue of that, um, that lifting, you will get a
degree of narrowing, but not, you know, not, not excessively so,
um. The other thing that you can do is um you can
sometimes use fat or combine fat to try and soften an appearance.
So if you combine plane change with a slightly wider implant and use a bit of fat,
you can give the impression that you're closing the gap,
bringing breast together um without really changing nipple position,
um, on the basis that you can't really do that.
Um, and again. Um, if you see this lady, uh,
before and afterwards, um, and I showed patients these,
these, these pictures, you know, she still remains pretty separated,
you know, there's nothing you can do about that, you know,
that's, that's just the way you are.
Um, and they, they'll say, oh, but I, you know, I'd like to be more,
well, you know, no can do, I'm afraid.
Um, and again, this lady here, she's kind of swinging to the side.
She stays to the side, those nipples are central on that mound.
And as long as I'm explaining that and managing that expectation,
then it's fine, and again this lady here as well, and I showed it when I showed them,
they said, oh yeah, but her breasts are a bit far apart.
I said, well, that's, you know, that's that's the way she is.
The other thing to say is, I think I'd probably spend more time lateralizing nipples than
medializing them. So if you look on these two images,
um, I think it's both on the left hand side.
Um, if a supra medial pedicle is my preferred pedicle for something like a breast reduction,
I'm not gonna be able to use it on that left breast because that pedicle length is too short,
the the nipple is too medial, so I actually need to lateralize the.
Um, the, the, the, the nipple by using a super lateral pedicle on that side,
and only by doing that, am I gonna get, um, you know, central,
central nipples. And likewise with my augmentation masturexy,
this lady, particularly on the left hand side, has got a nipple area ular complex which really
comes along that medial border. So, um, I don't know my little pre-op.
Anyway, so what I've done is actually, you know, try to lateralize it,
so. Um, not a huge else to say about that,
other than, uh, yeah.
Sorry, I couldn't give you any tips.
Mm Thank you, Patrick.
Um, we're now gonna hear about managing the fibroglandular breast in breast augmentation,
and, uh, I'm looking forward to this cos I think it's a a real challenge in those stiffer
tissue to patients. Oh, thank you, thank you,
Marlene. For this topic again, so I, I really think.
I really think that uh without any doubts breast augmentation remains as the perfect
brand for every cosmetic surgeons all over the world and when when we're gonna be talking
about uh fibroglandular tissue.
It's the only reason why we have to take care about fibroglandular tissue is because this can
pose unique challenge for both the patients and the surgeons,
yeah, especially when we're doing uh breast augmentation and uh when when we're doing
this we have to take in uh in consideration several things this can influence the surgical
approach. The implant selection and of course the overall
outcomes of the surgeries so.
Fibroglandular tissues has to be evaluated perfectly in advance of surgery so we need the
all the image in order to understand how much, how much of these fibrous tissues are remaining
in the in the gland.
Because all these fibroglandular tissue is not all the thing that a lot of fibres inside the
gland with less fat that we usually see in our patients so it really remains a
challenge to be working with these patients during the breast augmentation.
And uh obviously what we want to know is how it's gonna be dependent on the relation
between the implant and this fibroglandular tissue that we're gonna have in order to notice
if we're gonna have a demarcation of the implant or if we're gonna uh have a good
relation. So the first thing is that we need to
understand the very scholastic properties of the skin and of the breast and how much of this
fat or fibrous tissue we have in the gland content and of course how's the demarcation of
the inframammary fold.
And Once we have this we most understand that every shape of the breast is totally different
from one patient to another and we might have more fibrous tissue,
more fat tissue, and this will depend on the on the way that we're gonna deal with this,
but. On the other hand, we also have a lot of
asymmetries not only on the gland but also on the on the chest wall so we might have
alterations on the sternum shape alteration of the rib cage so we have to take all this
consideration before going into surgery.
I don't know if it happened to everybody, but at least in my practise,
everybody thinks that it doesn't matter how they look,
they think that an implant is gonna solve the problem by itself.
And well the thing is that we can see that each one of these cases has to be uh managed in a
different way in order to achieve a nice result so I think that this is
why the implants have so many different shapes, widths and and
heights because with this in mind we can really choose the perfect implant for the perfect
patient. And having said that, I, I really like the
ergonomic system and for me the ergonomic system is nothing else that understanding the
width and the height.
Of the patient and then we can put this in the perfect implant that we're gonna use so
as uh take Pat said before it's not a matter of the volume it's a matter of the
width and the height of the of the chest wall, the ones that we're gonna be dealing with.
And if we do this, then we know now that uh high cohesive gel fill implants are the perfect
option because they will at least maintain the shape longer than it used to be with the
implants that we use on the uh late 90s and at the beginning of the 2000.
Our uh preference uh anatomical plane for implants definitely is the
subfacial. And basically and probably it hasn't been
proved yet but I think that when you leave the uh fascia of the pectoralis muscle
with the gland, the possibility of contamination with the glands and the ducts is
a lot less so possibility of capsule contraction is a lot less uh if you follow all
my uh previous publications on gluteal implants, we never have capsule contraction.
And that's because we don't have anything to have a a uh contamination in the pocket.
I mean if you have a wound that he you may, but definitely not when you do not have a
contamination in the area, the possibility of capsule contraction is a lot less.
So, uh, if, if we try to maintain this and we leave the fascia with it and with the with
the uh gland, then the possibility of having good results is a lot most important so the
ergonomic, uh.
System uh consists if we can have a perfect relation in between the implant and the chest
wall and with this we're gonna be able to have a good result.
We prefer polyuretin coated implants, specially in fibroglandular tissue because we need a
complete adherence the implant to the muscle and the gland to the implant and the only way
to have it is when you have a polyuretine cover implant and if we do that.
Uh-huh. The possibility of inserting a polyuretine
covered by the axilla, it's impossible, especially if you're gonna use an anatomical
implant. So I would preferred approach in, in,
in breast augmentation with fibroglandular tissue is through the uh axillary through the
infant mammary sulcus.
Let's see some cases and.
Uh, as I told you, our preferred space is the subfacial space.
So in this case we have a fibroglandular, uh, tissue in this patient with very short
inframammary pole. So we need to expand the inframammary fold.
So we're not going to lower the inframammary fold.
We're gonna expand the in the the lower pole of the breast.
So in order to do that.
We're gonna do the planning of the surgery, we're gonna do uh um an abdomen,
uh. Marking at the same time and we started using
the subfacial space.
So remember that the pectoralis muscle doesn't go all the way to the infra mama sulcus that's
why you can see there's a a a little space of fat until we found the fascia of the
pectoralis muscle we raise the, the fascia and then we're gonna insert the implant and as
we're going to expand the lower pole of the gland we're gonna insert.
Uh, a polyuretine cover implant in this area and we're gonna fix it right in the
inframammary fold but we don't want to break the inframammary fault and so what happened
when we finished we obviously we see the patient because remember that the polyuretine
cover implants they will never move so the way it's gonna stay when you see it in surgery it's
gonna stay for the rest.
So uh especially in these cases you need to see the patient in order to see where is it and
then we always do uh inferior flap in order to have a perfect closure of the pocket that
doesn't remains with the with the wound so in case you have a little adhesence in the wound,
it will never go all the way to the pocket.
So that's why we use this a small uh flap that we use and we can see here the the post op of
this patient that uh one of the great things that I was telling you is and you can see it in
this slide is that we expand the inferior pole of the breast without going farther down to the
inframammary fault and on the lateral view you're gonna see that we were able to really
expand this area.
And to deal with the fibroglandular tissue, this patient and getting a good result.
This is the way that we use uh the the implants.
What but what better way to deal with fibroglandular tissue than with a tuberous
breast tuberous breast has basically.
A, uh, fibroglandular tissue we know all these concentric rings that goes,
uh, in the periphery of the areola that makes all these glandular fibroglandular tissue goes
through the areola and once we see this well we have to deal with it in these cases we,
we have to do something to the to the tissues.
So the main thing is that we're gonna open the fibroglandular tissue in order to have better
contact with the implant so we're gonna be opening in 4 different spaces that they will
look like this. Here's what we're placing the implant,
but what we wanna have is want to open the fibroglandular tissue and get a better contact
for with the gland and the implant and now with this in mind we can have.
A better result here you can see a patient that we did 14 years ago and what happened in the
beginning when we finished this is uh the patient just uh 5 years after surgery you can
see that we placed through any periareolar incision we placed the implants and
obviously we opened the fibroglandular tissue or we we break.
Take the rings and we basically have a very nice result after doing all this,
but at the same time, what happened with the stability of the surgery that we've done?
Is it able to last for 14 years? Here you can see what happened 14 years later I
did uh resection of the periaola in order to have a better size of the areola,
but we didn't go into the. Implants as they are polyuret and covering
implants. Implants remain in good stage.
There's no capsule contraction and so you can see that the preoperative 5 years later it's 14
years later and the patient remains the stability of the implant is maintained through
these 14 years and we can see that the inferior pole of the breast have a very nice and good
expansion that it was needed.
And you can see that the cleavage has been improved after 14 years and.
When we did the the areola resection that that was just something different.
Well, now this is another case of the tuberous breast, and we will have exactly the same uh
amount of uh fibroglandular tissue and we're gonna uh do exactly the same we're gonna open
it we're gonna place the implant we're gonna do it in the in the subglandular space as we're
gonna open this uh.
Gland and this is how she looked 6 months after surgery and you can see that we had the
opportunity of breaking the the rings that are concentric and we have the opportunity of
expanding the lower pole of the of the gland just by doing uh this uh this is another
case but here probably the most important part is the inverted nipple and dealing with
inverted nipple we normally place a little bit of a.
Uh, of, uh, uh, dermal fat gland, uh, dermal fat, uh,
graft when we finish opening and sectioning all the, all the,
all the conducts that are, uh, very short and when we place them then we have the
opportunity to maintain the projection of the nipple when we finish this is gonna stay there
it's a dermal fat graft that we use in the space that we open,
uh. When we finish the surgery and we can see the
patient a key months later and we can see that the projection of the nipple is gain and even
though it was a very fibrous tissue we had the opportunity to deal with the tissues and
maintain uh the position that she had before.
And even though we can do this exactly on the periareolar approach again when patients lose a
lot of weight and they just have this fibrous tissue with it and basically what we can
achieve is a very natural shape polyuret and, uh, uh,
cover implants are the ones that we really like the most and what happened with patients that
we had this asymmetry I told you before that if we can.
Get symmetry in this patients using energy like ultrasonic lipos culture but at the same time
if you see the patient, she had a bulging in the upper part of the abdomen.
She had a previous surgery they tried to do an abdominal plastic with a very small incision.
They never get on the sternum, so I decided to go through the inflammammary fault.
And uh doing this it means that I'm gonna do the mastopexy.
I'm gonna deal with the asymmetry of volume on the on the breast and at the same time I'm
gonna close the rectus abdominal muscle through the inframammary fold.
Here's what we're doing uh we're we're placing uh Barb's future.
Bringing together the uh superior part from the umbilicus to the sternum,
the rectus abdominal muscle and you can see when we do this we really have a better.
Uh, country on the abdomen and of course we deal with the asymmetry of the breast and the
position of the nipple areola complex and we did we had the opportunity to gain and here is
a lot of patients come to us after a breast reduction with very bad,
bad, uh.
Results, the thing is that we have to maintain the position of this so polyure to cover
and we resect most of the fibroglandular tissue in order to maintain the space for the
implant, the polyuretin implants so we're gonna resect this part of the tissue.
And when we do this, then here we can see what happened if we need a little bit of fat in the
in the cleavage we do it at the same time and so we can maintain the result longer than we
had with the previous uh surgeries that she had and the last case is exactly the same the
patient with a bad result after breast reduction.
And so we had the opportunity to reposition the nipple areola complex and and do a
better solution.
So I think there's uh working with the fibroglandular tissue is always something we
have to have in mind.
We need image before the uh every case so we know what to do and how to deal with this ones.
And I think we should take care of exactly all this uh and taking care of the implant
that we're gonna select specially when we're dealing with uh fibroglandular tissue thank you.
Yeah. Thank you.
Thank you. Our next next speaker from Brazil,
Adel Bark Junior, thank you very much.
He's going to talk about how is the management of the access.
Axillary skin in breast reduction surgery.
Once again, thank you very much for the kind invitation.
How to address the excess axillary skin in breast reduction surgery.
Again, my conflicts of interest, the papers that we published our breast scars,
and I tried to resume a little bit of the mode concept in 7 steps.
First diagnosing.
Uh, what kind of thorax that is quite important because the car thorax will just,
just make the all the breast slides down narrowly and of course we're gonna have more
tissue learned to deal with it's gonna be a kind of larynx placement of the breast tissue
and that leads generally to enlarged uh enlarged lascar to solve the problem.
Secondly, let's associate the skin.
And the parent man and and that's that's one main base of the mo pain concept we use
the cavalry we keep 2 to 3 millimetres of the fat attached to the skin to preserve the
subdermal vascularity use our left hand to guide us as doing liposuction.
So we're going with the cal parallel to the skin.
And with that, we can undermine the whole inferior pole of the breast.
Now let's undermine the para income as well. So we will do a,
a, a large sub glandular undermine as well as we see the necks are already in place,
so we raise the neck at the beginning of the surgery and,
and we undermine all the way to the inner axillary line,
leverage to the an axillary line immediately as much as we would undermine for a subglandular
breast implant. So the pama is literally in our hands.
Uh, let's do the layer resection of the, of course, many of these patients,
this is, these patients are all without implants, OK?
So many of these patients get this bulky leo side boob.
so we reduce and what it matters what remains 1.5 to 2 centimetres of the breast and
that reduces the volume and the weight and let's fixate the para uh.
And this is the way we do it, uh, we start positioning or,
or, uh, pulling the parama on a caudal and medial rotation with that
we simulate the gravity at the same time that we're just reading and bringing out the breath
more immediately. So that's the concept.po it's caudal and medial.
And we was in a one bike r, absorbable stitch.
I really think that the technique is much more important than the truth bars all these kind of
things, but when we think it's necessary.
2.5 to 6 stitch later, 2 stitch immediately.
And this is, this shows exactly what multiplane is.
We're doing, oops, not working. 6. All right,
there we go. We have two concepts horizontal excess and
vertical excess. So whenever you undermine the skin,
this is the middle part of the breast.
This is the lateral part.
So this is the first one is middle, the second one is later.
So the main idea is to completely do a huge invertity and have no redundancy in any part
of the breast. So we just play.
Kind of joke that's kind of a legal that gets joke that legal the idea should have and
there's no perfection but matches as as more would be perfect as
possible the parma without any redundant so we start our invertedity at the level of the
standard and go all the way to the interline and that's basically what we do.
So we're resecting.
The redundant of the perma uh on the inferior pole of the breast and do a tension free
closure of the skin.
So the tension, the pattern that we treat the skin is completely different that we treat the
parema. So I've made for this patient a huge invertity.
But these small A scar shape and we talk about we do we've been doing this for 20 years
with over 4000 patients we were talking about that scar for a long time really think that we
must try to get the patients rid of this media scar on breast area.
And on table can not on another patient, even on bigger breast,
and this is the concept neck in place we placed that in the beginning of the surgery raised the
neck at the beginning of the surgery.
There's no redundancy, no, uh, perineal resection of skin,
uh, raising the IMF.
And can address all these issues. Look at this patient we've performed,
uh, this is Hiberro's flap in the middle 37 centimetres of horizontal resection,
and our BC would be 26.
So we performed this huge resection with this car limited to the interior
line and not resting and this is a 15 days postal.
We just perform the surgery, but in any surgery that we perform,
they they should have this. We can reduce the weight of the breast.
We can have the neck in place. We don't have shoulder sect tissues,
but that's because we're treating the skin on a complete differently from the traditional well
that's a rotation of the breast we do internally in verity.
And early postto I want this fullness of a purple and flatness of the inferior pole of the
breast due to the, the, the vascular effect, the breast will fulfil the inferior pole and
the lateral part of the breast as well.
Uh, another breast reduction 3 days we use a drain on this subglanderary space.
This, this space that's been undermined, uh, 15 days post op.
We can raise the MF in secondary surgery, and we can complete the re the later part of the
breast without a scar that goes further than the anterior oxy line.
14 years old patient, very young.
Uh, uh, we respected 300 grammes per breast, and we have a small uh
scar for her. So the idea is that you can treat every breast
without a bit of scar and you can address the later part of the breast without over,
uh, going with the, the horizontal scar. Same thing,
small L scar breast reduction 350 grammes per breast plus,
uh, lateral liposuction.
So, uh.
We cannot show the whole concept, but the idea is that I cannot make it better with familiar
scar. I cannot make it better with, uh, uh,
longer la scar as well. Plan thorax scar and not on thorax,
both without implant. Show my patients this because this patient
wants a pretty, uh, tight cleavage and say no, it is impossible for you due to your thorax,
but we can treat. Both and 4 years postop as time passes by and
this really depends on the patient discipline to maintain weight and to maintain hormones and
to use the bra. I need 3 things to have a long term result
without implant 55 years old, 7 years post-op, a scar.
Uh, roundness of inferi pole of the breast and the lateral part lateral axillary skin
completed treated without.
A scar so we can just treat the skin on a different part and then the
the the the perma and have the whole breast treated and give our patients the freedom to
choose their bikini and their clothes. Thank you very much once again.
Thanks so much. I'm looking forward to hearing from Mark or
Mark Raber in the UK about his approach to gynecomastia.
Right, uh, good evening, everyone, and thank you for letting me speak here.
Um, breast is a, you've been listening to all these great surgeons about how they can improve
the breast, what's a perfectly uh breast shape is like,
but if you're in the manga world, the Patrick Mallucci's 4555 does not work because that's
not what they want.
The thing about masculinity is actually defined by a well-defined torso and a good uh border of
the pectoralis major.
And master of men boobs is not nothing new. It has been going on for years,
as shown in these statues.
And in some culture, like the Chinese, being a little bit overweight and having master is a
sign of happiness and wealth.
So over there, I'm not thinking you're gonna get a lot of business by doing this surgery.
But with the explosion of the internet, reality TV shows,
social media, I think there's a lot of pressure on the younger mans when their body does not
conform to these uh supposedly perfect body that is seen on the televisions or on the
internet, and there's a lot of psychological study on how it affects them.
There's been the number of consultations definitely on the increase,
at least in my uh clinic, and most of them will tell you that they've been going around to gym
on a regular basis, but they can't lose the men boobs, they've been toning,
but it's no different. And all they want is to have been able to wear
a tighter top or being topless at the beach to play with the grandchildren or whatever they
want. But what's really fascinating is the last 30
patients I asked them, I say, how do you find me?
He said, well, actually, I've been looking around for years but never heard of anybody
doing the surgery.
I think maybe it's just because men don't want to share about the body or they're not
discussing, so it's something that we should, as surgeons go out there and broadcast as a
simple, relatively straightforward surgery to improve their psychological health.
I'm not going to waste time to talk about the aetiology, everyone knows about it,
except for the fact that there are more and more medications that seems to be inducing
gynecomastia.
There are few classification out there, but I don't think there's anything very helpful.
They just seem to categorise patients in the different groups to help us.
A lot of my patients would have been seen by a GP or a breast surgeon or an endocrinologist
and try a course of pharmacological treatments, particularly tamoxifen.
They usually try for about 6 months, but most of them seems to fail once they stop the
tablets. And so it's one of those things that for
transient reason, it may not be a bad thing, but I don't,
I have not seen anyone that have successful results with that.
When I was a junior surgical trainee, my boss taught me how to do a subcutaneous mastectomy
on male gynecomastia.
You give a long transverse scar, take out every single bit of tissues,
and then you end up with a terrible aesthetic result with tising and inversions of the
nipplearyo complex.
And thank God for the inventions of liposuctions.
It really has transformed the result and what we do to uh gynecom masia patients.
Lots of us have specific interests in what type of uh candle that we use,
whether it's a basket or a uh free hose or 5 holes, whatever you want to do or different
machines. I've tried quite a few of them, but I find that
ultimately they pretty much work the same, and I can't see much different in the result that I
use. So use something that you feel that you're
comfortable with.
Infiltration relatively standard, I like it, it's super wet technique.
And when I first started doing this surgery, I used to just mark out the whole chest and I
would suck everything.
And end up not looking great.
Now, as I get a little bit older, I leave the super media polls more or less completely alone
and just simply concentrate on the infralateral aspect where the gynego mast tissues are.
By leaving the upper part, I think it helps to exaggerate the pectoralis major and give a
better contour and contrast to the with the chest wall.
So once I performed the liposuctions, I removed the glandular tissue.
I personally like to do it through a very small infra memory
uh not infra infra area all the incisions.
I like it more because a lot of patients like the idea of having inconspicuous scars
afterwards, but it does make the resections a little bit more,
take a bit longer and more trickier.
If you make it longer, it comes out a lot easier.
And also in my hand, I find that if I make a shorter scar,
the adhesion rate between the scar and the chest wall become less,
because a lot of them come back in about 6 weeks and they say there's a little dip just
below the areola.
And you just say simply massage and that will do, but by making it shorter,
it seems to have less of an issue.
Thank God that majority of the cases are relatively straightforward on a younger man.
They, they are not grossly overweight, they train hard and once you perform the liposuction,
they, you have a much better definition of an infralateral border of the pack to race major,
and they're usually very happy with it.
Some of the thinner one, you get less definitions, and there is a small group that
what I call puffy nipple areoli syndrome, they hardly got any fatty tissues,
but they just have a herniated nipple.
Those are the case that, You've got to be very careful.
Uh, some of them will say, oh, I just do a bit of lipo.
You really do need to remove the glandular tissue, and they really do spread out much
wider than you think because normally it's retro-alveolar, but these group of people,
they always seems to spread into the anterior axterior line,
so you really have to be pay attention to it. If not,
then they'll come back complaining of a little small lump on the side.
So, gynecomastia is best treated with surgery, and the next group is slightly more tricky,
and the one with the skin excess, whether they're a little bit older,
whether they have massive weight loss, and.
There have been many techniques being talked about in how to treat the skin excess,
whether it is a Webster, Davidson or Pateni technique.
The circum Marriola technique is good because it's limited to scar to circum Meola region,
but, I personally dislike that simply on the basis that you cannot control the lateral
excess in the axillary area. So if someone got quite a bit in that area,
just be careful about using this skin reduction technique, simply because you can't do that
without limiting the rate of abductions of the arm and stretching out the scar.
If you do what Dr. Burg does with a bit of electro extension,
then you are destroying the purpose of limiting scar on this group of people.
I think the majority of cases now I see, I prefer to do a inframemb
inframembory incision simply because a lot of them has uh prosthetic cancer and they've been
treated with Solidex and the excess is more than a circum and areola can reduce.
But the worrying thing is, what do you prefer to use?
Do you prefer to use, keep the nipple on the pedicle or do a nipple graph?
Each of them has their own merit.
Keeping on a pedicle, you have a little bit, uh, you get the uh circulation,
but you have a little bit of puffiness in the lower border.
In the nipple graph, you can have better definitions of the pectoralis,
but you risk the chances of having so uh just uh nipple necrosis or pigmentation changes.
For this type of surgery, where do you place the nipple areola complex?
There's been a lot of paper written about it, and even a very complex formula,
where you're gonna place it.
I'm not that clever and most of the time I simply place it just lateral to the meridian
line. And measure approximately 43 to 4 centimetres
from the memory fold uh area, because at the end of the day,
it's really depending on your skin laxity and how much pectorus major muscles that you have.
I think we all agree that the sky is not very pleasing, and if you can avoid it,
I think you should.
And this is a group that really particularly difficult because you feel that they will have
some loose skin and, But it's not bad enough to have a really bad scar,
and you need to tell the patients.
So, and also a lot of patients do not want scar, especially when you show them the photographs.
So you go back to the basic that you need to have a good consultations and manage the
expectations of the patients.
You look at the patient, you check the skin excess, you measure the volume that you intend
to remove and how much weight loss they have.
And then I normally would draw in front of the mirror and say,
this is where I'm gonna place the scar, this is the amount of tissue I'm gonna skin I'm gonna
remove if you want that scar, but it will have some concertina effect and some still have some
laxity because you've got to move your arm.
So patients will then decide and help you decide, and a lot of them would just say,
look, I simply just want reductions in the volume and if I don't like it,
I'll come back for a second stage.
And also, the thing is that without the scar, they don't have the stigma of having surgery.
So ultimately, commasia surgery is relatively straightforward and minimal complication,
but The complication that really bothered me a lot used to be is the hematoma,
because they do bleed and it's usually a few hours after the surgery and then you get called
back and you're gonna take it down to theatre.
So, I learned that from my colleague, Mr. Carridis, and now I quote every single patient
like Avo does with the neck.
You, I use a 40 prole simply because it's got big needles and I just go around picking up the
fashion and the skin and quilt it.
And then what we do is that we put a helo foam, which basically just cool it down for 4 hours
and then send them home with a uh compression garment.
What it does to it is that I look back at my old data,
I used to take about 5% of patients back in the evening to evacuate the hematoma and then
put them back. And then since I started quilting,
I haven't taken back anybody, which is great for my sleeping out and my wife complaining,
me being at home a little bit longer.
The quilt only lasts for 2040, 48 hours to avoid any pigmentation mark,
especially on the darker skinned patients.
Yes, you still get, can get hematoma, but because of the quoting,
it limited to a certain area and then you can easily aspirate it or you can express it.
So in conclusion, it's a surgery that doesn't seems to be known by a lot of our patients,
but it is a very effective surgery and patients do have very good results with minimal
complications.
And thank you once again to LBM and your 10th anniversary, and it's great to be here again.
Thank you.
Thank you very much. Our last speaker on this,
on this section will be.
Charles that Thank you very much for being here.
Mike. OK.
You know, when you're given a task, it's interesting the title,
this is quite a long title.
Implant Choice Following removal of Anatomical Implants and Strategies for pocket Control.
That could be a big and difficult or You could shorten it down.
We'll see what goes on. So with that said.
These are my disclosures.
So once again I tell my children this when you wake up in the morning,
why? Ask yourself why.
Why is the patient requesting a secondary breast augmentation?
Aesthetics, size, shape, or also functional mechanical complications.
So there's 7 reasons why they want to why they might want to move away from because the task
was anatomical.
An anatomical in general means textured, although they're anatomical smooth ones,
but they're not big on the market.
So what is the reason? Why does that patient come to your office?
And then the question arises, what?
What is the solution?
Well, depending on the reason why, if for aesthetic reasons,
what are the guidelines? So with everything we have to have an aesthetic
sense. What's our objective and do we understand the
patient's objective, and I work with the golden ratio, the Fibonacci code.
It's been guiding me through my life, finding that balance,
what I think is in relationship with nature.
So I always try to reproduce something that's proportional and well balanced.
Not exaggerating, that's why if someone wants big round breasts,
no, I'm sorry, I'm not the appropriate surgeon doing that,
and I'm not putting any um.
Validation in that it's just it doesn't follow my aesthetic guidelines.
Cert the Fibonacci code, 1 + 1 is 22 + 1 is 33 +, etc.
Now I do believe, and I absolutely agree with with what Pat has done previously,
that the beautification of the breast is found in its lower pole.
And I try to create that, regardless if I work with a round implant,
anatomical implants, smooth or textured.
And the balance between the breast width and the nipple complex and IMF.
So those are my objectives and uh.
In most cases in my patient population, that's what my patients want,
having seen me do what I do for 30 years.
So the question is, when she walks into your office, she has uh this device,
she's not happy. I think we're all aware of why she isn't happy
because she's unbalanced. She has 170 saline implants.
The only requirement, the only desire from her side is,
you have to understand, Doctor Rehnquist, I don't want to go bigger.
So I suggested more than twice the size, and of course she questioned that,
but I said what is bigger?
And in general, when women talk about, sorry, bigger, they talk about projection,
they don't talk about width.
So being able to understand that and providing something that is bigger per volume.
But not bigger in the sense of projection, understanding that this is 200 and this is 200,
the same volume but there's different volume distributions enables the patient to understand
the concept when we guide them, wanting to change for whatever reason.
So, twice the size, but not more projected, just more well balanced,
which is really the objective of all of us.
So C says the number is of no importance, how we distribute it is.
It's all about volume distribution.
So with that said, There are different techniques that we
have developed within the practise based on the fact that most of the textured implants I've
been working with, they do create more capsule formation.
Now my choice in secondaries in general is a smooth, soft er go to implant.
Now if you do put that implant in to the breast.
Not adapting the capsule, that is the capsule formation, you will not have all the benefits
of that smooth device.
Now you have to understand these are patients that don't have any history of late seromas.
These are healthy patients that for one or another reason want to change their implants.
They might even have a capsule formation, but there are no seromas involved.
That's a different topic.
So this lady walks in and she has 3 pregnancies and this is
basically uh uh the plan I had. I'll get back to her.
The easiest case can become a challenge if you do not have a plan.
So we've developed these concepts that we follow, quite rigid as step by step and in
our practise.
The first and most important choice of technique is the popcorn.
Uh, we utilise that in most of the cases. Now the weakness with the popcorn technique is
that you have to have a fairly thin capsule to create, uh,
um, the popping and the shrinking of that capsule.
The second is the doughnut technique we will remove and I'll show that remove some of the
capsule to have the benefits of the softness of the breast,
so the breast feels soft and gentle.
And then we have the anterior capsule flap, which I'll also share with you,
which enables us to both lower the pocket or put it higher
up by basically opening up the capsule from the posterior side and recruiting that capsule,
opening it up like.
An orange, and then we can utilise that reattaching it on the rib cage where we want,
and then reinforcement with the lockate stitch.
And then of course the possibility if you've removed all the capsules you don't have the
stability, you still want to move forward with a smooth and not a textured or a polyurethane,
one day you have the measures, and then always the change of plane with the concept today in
our practise with tissue preservation, which I'll talk about in the next talk.
So this is the texture form stable, control tissue expansion,
stability over time, we've all heard that.
And it's a perfect tool in a lot of patients.
These are the smooth ones, uncontrolled tissue stretching, and implants with less stability
over time. Now, let's look at the popcorn.
Can we have some sound?
Do we have sound? Yeah. No.
Well, pop, pop, pop, that that's basically what you hear.
Oh. OK, because it's maximum.
No, no, I'll just say pop up. I think they do.
It's OK. OK. So, so as you can see, what I'm doing here is
I'm, I'm basically taking an isolated forcep with white teeth so I don't cheese wide a
capsule. And once that's done, you can see that's how we
look afterwards. So you're shrinking it.
And I remember when I presented first time at Atlanta Breast Symposium.
16 years ago, everyone was, you know, in the belief that we would have seromas,
infections, it doesn't, and today it's a work tool for a lot of surgeons and it works very
well. So that's basically the baseline for us in
secondary surgeries.
And, and, um, this shows the stability of this. So this is a lateralized
implant and using the popcorn, general, we shrink it laterally and and distally.
And by doing that we can create it and it actually keeps up pretty well over time.
So this is a lateralized implant as you can see.
Dropping into the armpit, some call it the natural breast,
I disagree, I don't think that's very natural, and this is basically the stability that's
created with the popcorn.
Now then we have the doughnut concept.
So this is just showing the drawing.
So what we do is that we remove the anterior part of the capsule and then we open up.
So you can feel the softness of that smooth implant.
And the ergo 2 is really a very nice implant in its softness.
And then once that's done, I'll show you. So what we do is we remove from the anterior
portion, remove that, and then we've opened up so you can feel that softness.
So that's basically.
The anterior portion, so that we also do in the secondary cases changing.
And this is a typical case, a secondary.
Uh, we didn't know the implant. All we checked the patients before with
ultrasound, but it's not always easy to detect.
And this is 5 years after surgery, implementing these two techniques with the 380 CC
ergonomic implant.
So with that said, the third technique then is the pocket stabilisation with anterior capsule
flap, where you basically go from the posterior side, open up the capsule,
and then recruit it and then you can use that capsule, push the pocket.
Making it smaller Pushing it cranially or distally, and then you secure it with the lock
8 stage because if you release something, you want to create a stable environment,
reattaching what you've de-attached.
And that's interior capsule flap.
So the beauty with that uh uh flap is that you've recruited excessive capsule that you can
move up and down because sometimes the breasts are just too high up and you don't want to
remove that capsule because it's like a hammock for stabilisation.
And the 8 stitch is basically taking a sharp needle tip,
not a cutting one. I use the two ole.
59:56.770 --> 01:00:01.560 I go inside, grab the perichorium periosteum, and then I go from inside out,
01:00:01.639 --> 01:00:06.129 grabbing scalpus's fascia and inside out, not puncturing the implant by keeping the needle
01:00:06.129 --> 01:00:08.929 tip away from the implant and locking it down.
01:00:10.739 --> 01:00:14.810 Now this is how it looks over time. The interior capsule flap going back in a case,
01:00:14.979 --> 01:00:19.979 as you can see, I've scored it, so sometimes I create a mesh so I can open up because it's
01:00:19.979 --> 01:00:23.139 tight. And as you can see, although there has been a
01:00:23.139 --> 01:00:26.129 smooth device in there, it doesn't create the same capsule formation.
01:00:26.260 --> 01:00:30.179 It just shows the difference in the biocompatibility of the implant.
01:00:34.199 --> 01:00:36.570 So number 4, the lucky 8th stage.
01:00:37.719 --> 01:00:39.199 Basically grab me prepare con.
01:00:39.760 --> 01:00:44.290 First I mark on both sides. I go down with with a needle tip.
01:00:44.439 --> 01:00:46.590 Why? Because if you put the stitch on one side,
01:00:46.840 --> 01:00:49.239 if you haven't marked on that side, you might create a symmetry.
01:00:49.280 --> 01:00:54.300 So it's just one of those safety points that we do.
01:00:54.560 --> 01:00:59.459 And then you grab it once again, per per osteum, go inside out.
01:01:00.070 --> 01:01:05.110 Lucky 8 because it's an 8 loop, and lucky because in Chinese it's a good number.
01:01:07.149 --> 01:01:10.270 Holding up, I can lift the patient off the rib cage with that stitch.
01:01:11.600 --> 01:01:14.729 So number 5, pocket stabilisation with mesh planning.
01:01:15.120 --> 01:01:20.129 So basically, I've used a lot of measures. I don't use alloderms,
01:01:20.159 --> 01:01:25.379 uh, um, I was never keen to try and work out listening to colleagues of mine and,
01:01:25.439 --> 01:01:27.719 and looking at the data. I like measures.
01:01:28.629 --> 01:01:32.229 They all have their pros and cons. I don't have any relationship with any company.
01:01:32.469 --> 01:01:34.300 This is a hammock designed one.
01:01:34.550 --> 01:01:38.669 So in cases where we don't have the civilization, where we still want to work with
01:01:38.669 --> 01:01:41.340 this smooth device, this might be an alternative.
01:01:42.530 --> 01:01:44.040 And I just lock it down.
01:01:44.699 --> 01:01:49.500 And with the popcorn, there's a fasting growth and we've seen that with biopsies.
01:01:49.750 --> 01:01:54.689 Now, finally last, the pocket, the patient walks in 1.5 kg,
01:01:54.989 --> 01:01:57.620 she wants to remove her implants. What do you do?
01:01:59.729 --> 01:02:04.879 So, um, very often we have a tendency to be a little bit too over aggressive.
01:02:05.169 --> 01:02:08.280 If you feel you can't ensure stability, stage operation.
01:02:08.570 --> 01:02:12.810 Whenever you feel you don't have control of the situation, stage the patient.
01:02:13.540 --> 01:02:16.530 That's true. You might think she walks away and you lose her
01:02:16.530 --> 01:02:19.209 as a patient, fine, but if that's what you believe in,
01:02:19.330 --> 01:02:23.469 stay true. And if you do, you can go from 1.5 to 350.
01:02:24.520 --> 01:02:26.760 Like this without any mass of Pixar.
01:02:27.909 --> 01:02:30.939 I've done in horizontal excision because that skin was destroyed,
01:02:31.070 --> 01:02:37.100 but combining staging with popcorn, shrinking the pocket in uh inside is a very helpful tool.
01:02:39.409 --> 01:02:46.250 So conclusion When we start off we think we know everything and we do
01:02:46.250 --> 01:02:50.689 all and then we get into trouble and then we get a little bit sad but then with the
01:02:50.689 --> 01:02:54.459 experience we learn even more with that said, thank you very much for having me here.
01:03:01.060 --> 01:03:06.250 I'm afraid um we are gonna move straight on. We don't unfortunately have time for questions,
01:03:06.459 --> 01:03:10.050 uh, looking at it, but please come and speak to the speakers afterwards.
01:03:11.629 --> 01:03:14.179 Oh, apparently we can have questions for 5 minutes.
01:03:14.310 --> 01:03:15.739 We're giving me the green light from Marlene.
01:03:16.030 --> 01:03:18.350 Does anyone have any questions from the floor to start with?
01:03:19.320 --> 01:03:22.929 Bye bye. You don't have to leave.
01:03:23.310 --> 01:03:26.229 No, you'll see the preservation soon. Now keep it on.
01:03:26.439 --> 01:03:30.750 Um, we've got, I've got a couple of questions, um, which would be,
01:03:30.840 --> 01:03:34.760 um, uh, which we kick things off with, um.
01:03:36.340 --> 01:03:42.100 Actually, Mark, can I start with you? Um, what about cases of pseudo gynecomastia?
01:03:42.129 --> 01:03:45.739 They're very fibro fatty gynecomastia where there's not much gland,
01:03:45.780 --> 01:03:48.889 it's mixed in with fat, and they've got a bit of excess skin.
01:03:49.060 --> 01:03:51.100 How do you deal with that sort of case? I think the,
01:03:51.179 --> 01:03:53.949 I mean, usually those cases they will contract quite nicely,
01:03:54.040 --> 01:03:57.395 so I don't I think you can take. The skin out of the concept,
01:03:57.435 --> 01:04:02.675 but I think I always have go going, I've never regretted going in through in from memory
01:04:02.675 --> 01:04:06.514 because they basically spread out like an octopus to everywhere,
01:04:06.594 --> 01:04:09.635 so you really have to pick it up because the more you resect,
01:04:09.715 --> 01:04:13.344 the more you're gonna feel those littered lump on the side and they really do hated it,
01:04:13.354 --> 01:04:14.425 so you've got no choice.
01:04:14.879 --> 01:04:21.840 And sometimes if they are adhering to the skin, then I will have to tell them that I may
01:04:21.840 --> 01:04:26.560 have to give them some steroids just to soften those little points like there's like a cyst,
01:04:26.889 --> 01:04:31.000 and they usually do quite well out of it, but you can't resect skin for that one.
01:04:31.169 --> 01:04:32.360 Any questions from the floor?
01:04:33.270 --> 01:04:36.459 Question first, you know, Charles, you can take this or any really anybody,
01:04:36.469 --> 01:04:38.870 but, you know, it's interesting how much I've noticed.
01:04:39.600 --> 01:04:43.739 In the breast reconstruction world, uh, the orientation of the chest wall,
01:04:43.909 --> 01:04:47.750 you know, sometimes these patients have a relatively horizontal chest wall and sometimes
01:04:47.750 --> 01:04:49.830 they can be dramatically oblique.
01:04:50.260 --> 01:04:53.679 And I'm wondering in the in the in the aesthetic patient where you're doing breast
01:04:53.679 --> 01:04:58.290 augmentation, are you doing anything differently in somebody who's got a not so much
01:04:58.290 --> 01:05:01.899 a chest wall deformity just a naturally oblique chest wall?
01:05:02.050 --> 01:05:04.489 Are you, are you always putting in a texture device?
01:05:04.570 --> 01:05:07.000 Are you always going prepectoral or dual plane?
01:05:07.250 --> 01:05:12.330 Are you stabilising anything laterally because they'll be prone to displace just because of
01:05:12.330 --> 01:05:14.719 the configuration of their chest wall.
01:05:14.929 --> 01:05:19.350 Now, where it's very, very good question and 11 of the things that I,
01:05:19.370 --> 01:05:22.770 I. I learned working with anatomical implants,
01:05:22.929 --> 01:05:25.270 and I started in '96 with this.
01:05:25.649 --> 01:05:27.239 The beauty with anatomical.
01:05:28.409 --> 01:05:34.120 Predesigned form stable shape is that you can change it.
01:05:34.169 --> 01:05:36.379 I mean you don't have to have the lower pole always.
01:05:36.770 --> 01:05:39.969 So for instance, when I have patients with severe excavatum,
01:05:40.330 --> 01:05:45.669 I don't use more devices because the thing is, even with a small push up bra,
01:05:45.810 --> 01:05:48.810 it looks like they have like uni breast.
01:05:49.500 --> 01:05:53.620 So in those I do rotate, I use the siltex.
01:05:54.020 --> 01:05:58.929 I rotate that implant to utilise the best shape.
01:05:59.360 --> 01:06:04.790 And the same applies, of course, when they've got the difference that they've got.
01:06:04.939 --> 01:06:07.840 I rotate the implants so I have the volume stabilised.
01:06:08.139 --> 01:06:14.780 So in severe cases, in those situations, yes, there are benefits in thinking outside the
01:06:14.780 --> 01:06:17.899 box. May I, may I complete?
01:06:18.570 --> 01:06:22.439 Uh, in modern dual plane, what we do like an excavatum patient,
01:06:22.520 --> 01:06:26.260 we preserve the pinates, the deeper insertion of the pet measure,
01:06:26.639 --> 01:06:31.399 and we open wide the la we have no las link, for example,
01:06:31.679 --> 01:06:34.189 when a carnaum patient do exactly the opposite.
01:06:34.479 --> 01:06:36.419 We open the pinates completely.
01:06:36.760 --> 01:06:40.909 We have a really small middles link and we have, uh, a thicker,
01:06:41.199 --> 01:06:46.919 not thicker but wider, not thicker, wider, uh, las link and sometimes use the back minor as
01:06:46.919 --> 01:06:50.969 well, the grip lane. To to hold, so whenever we're talking about
01:06:50.969 --> 01:06:57.739 submuscular nowadays we can customise it's not always the same thing and we also use myotomies
01:06:58.050 --> 01:07:00.879 and carryatum. We, we do myotomies from the second.
01:07:01.340 --> 01:07:06.699 Uh, all the way down to the 15th course of space opening the deeper layer of the peck
01:07:06.699 --> 01:07:12.419 measure to make the, the muscle weaker so we have less pressure on it but just the,
01:07:12.459 --> 01:07:15.409 the deeper layer of the peck measure so dealing with the,
01:07:15.419 --> 01:07:19.260 the muscle we can minimise the the thorax effects.
01:07:21.209 --> 01:07:22.679 We've been one more question.
01:07:22.969 --> 01:07:25.500 Anyone? I've got one if no one else has.
01:07:25.790 --> 01:07:28.290 Patrick. How can I help.
01:07:31.239 --> 01:07:37.010 The um medialization or lateralization of the, which you're clearly an expert on,
01:07:37.020 --> 01:07:39.979 to the right guy? It's for everyone's benefit.
01:07:40.100 --> 01:07:41.689 You need it. Thank you.
01:07:41.899 --> 01:07:44.810 Um, I don't know if you've heard any of the talks that,
01:07:44.860 --> 01:07:48.090 uh, Mike Morosnik has given from Sydney.
01:07:48.770 --> 01:07:51.750 Well, he haven't, so this won't really help, um, but I,
01:07:51.870 --> 01:07:58.110 and I've not tried this, but for exactly this reason, he skews his dual plane approach with
01:07:58.110 --> 01:08:03.540 uh a variable release between the gland and peck major,
01:08:03.870 --> 01:08:06.750 um, so it's not a uniform release or even a U-shape release,
01:08:06.790 --> 01:08:08.899 it's maybe only released medially or laterally.
01:08:09.449 --> 01:08:15.760 In an effort to try and affect the position of the nipple relative to the gland for his
01:08:15.760 --> 01:08:20.600 outcomes, he shows some good results, but obviously you haven't had an opinion on it if
01:08:20.600 --> 01:08:22.720 you haven't seen it. I don't know if anyone else has.
01:08:22.839 --> 01:08:26.109 I, I mean, sure, maybe he does that, maybe it works or whatever,
01:08:26.359 --> 01:08:29.410 but I do think that the main thing, the main message, especially for the inexperienced
01:08:29.410 --> 01:08:34.779 surgeons, is managing expectation because, you know, uh,
01:08:34.890 --> 01:08:38.160 you know, often you're just not going to be able to get that narrowing that they want.
01:08:38.600 --> 01:08:41.919 Um, and you might make it visibly worse as well by enhancing them,
01:08:42.000 --> 01:08:44.859 so I, I think that's the main, yeah, I, I totally agree,
01:08:44.959 --> 01:08:47.870 you know, if you think it might make it worse, avoid it.
01:08:50.229 --> 01:08:56.450 I think it's important. nipples in specific cases and and the patient
01:08:56.450 --> 01:09:00.040 wants that cleavage, you're enhancing the issue and the problem,
01:09:00.089 --> 01:09:06.250 so it is very important to make them understand that this is your biology,
01:09:06.290 --> 01:09:10.850 this is the way you look, and if that's understood, I think we'll be better off in
01:09:10.850 --> 01:09:16.419 general. Great, and that leads us very nicely on to the
01:09:16.419 --> 01:09:18.770 end of this panel and to your next talk.
01:09:19.180 --> 01:09:22.100 So uh thank you very much everyone who's been part of this session.