Hello everybody. Welcome back to the final session for today.
Just a couple of announcements after this talk, there'll be a group photo,
so please stay, hang around. We'd like to include as many of you in the
group photo as possible.
And the second announcement is that there's a party tonight,
so for those of you who still.
Are considering coming, please come, um, register at the front desk for it.
There's loads of spaces available, so come and join in,
it'll be fantastic.
And with that, I'm just going to hand over to Marissa and Eric for the next session.
OK, thank you. You can actually I'm gonna actually grab a pen
What Go ahead and start.
OK, so, good afternoon.
This is, uh, the session that it's entitled Updates in Lifefulfilling.
One second please. And I think the, the first speaker,
um, well, I'm Eric Santamaria and Marisa Lawrence, we will be sharing this uh session.
And, and the first lecture is about lipofilling of the breast considerations.
Sorry, Alan, Alana Rebecca is presenting lipofiing.
And nutrition. No lipofilling of the breast considerations for
success and failure.
It's, it's mixed here.
I have no disclosures.
So the objectives of this talk are really to talk about fat as a filler,
the different um harvest techniques and preparation techniques,
um, and then things that affect long-term survival.
So fat grafting to the breast actually has a pretty broad range of indications as discussed
by Coleman back in 2007.
But as we think about fat grafting, the first introduction of fat grafting was really in 1893
at the German Society of Surgery.
The first discussion about fat grafting for a lumpectomy defect was actually back in 1895.
So it's interesting that it's been that long and we're still talking about it with as much
vigour as we are now.
Um, 1911 was soft tissue augmentation and then in the 80s when liposuction really became more
broadly available and broadly used, it, it assisted with um getting our fat grafts and um
the clinical utility.
So fats actually has the potential to be um a really ideal filler.
It doesn't have any hypersensitivity reactions. There's no foreign body reaction.
It's pretty easy to obtain as a filler.
The difficulty really with fat grafting is that all of the different literature talks about
different techniques. So the techniques um both of harvest and of
injection have been really variable. So in clinical situations,
we found that the results are somewhat unpredictable.
There are multiple ways to harvest with um lipoaspiration or a direct sharp harvest.
And multiple iterations of preparation techniques, whether it is gravity
or filtration.
The idea of preparation in the fat is really to gain a purified fat aliquat so that it's free
of cellular debris, free of lipid droplets and blood.
This is early on in my career, so, um, around 20 years ago or so,
I used to use the handheld technique and um do a gentle telfa roll for um preparation of the
fat. And you can see when you look at this fat
compared to the other fatty um aspirrates that we have and the preparation for injection and
what um the other speakers will, will show, this is a much more bloody specimen in
comparison to some of the other techniques, but this was um old style,
old school um preparation.
Next, there were several products on the market where you could assist with gravity preparation,
so you could either allow for gravity to happen in a syringe and decant the aquats of
debris, or there were some devices that were larger, up to 1 litre in size,
or you could suction into a sterile container and then allow gravity to do its work.
My um practise has switched over to active filtration.
So now I use an active filtration device. So um it's rinsed through a mesh and um this
gains some really great fat that's um in contrast to the handheld Telfaro.
This is very um golden and lovely um for injection.
So this review article actually um evaluated the different harvest and injection techniques
and something to note as we look at some of the articles.
This was before the widespread use of um active and passive filtration.
And so what this review found when it looked at the literature was that the donor site in and
of itself does not actually affect uh graph survival, but a slower injection speed
actually will assist with a longer and better survival of the fat graft.
Looking at the different methods of um of preparation, centrifugation,
gravity, and um washing, washing and filtration appears to have a much higher viability of the
fat graft than the other methods.
It has less contaminants and so um seems to work better.
Summer Hansen and um her group actually took these articles and among others,
and did a prospective randomised trial of different types of harvest um techniques and
preparation techniques.
And what you can see here is they looked at the passive filtration,
active filtration, and centrifugation, and looked at the time involved versus how much fat
they actually got.
So, um, here you can see that there was much higher volume obtained actually in the active
filtration group than the other groups.
And it was statistically significant for the um ratio of available fat in the active filtration
group than the other uh preparation groups.
So it was a small sample size, which was the limitation of their article,
but it was randomised.
All groups had approximately the same amount of fat necrosis at 12%.
The groups were similar in demographics. They all required additional fat grafting
procedures. Um, a third of them still had contra
deformities, and interestingly, in breast conservation, lumpectomy,
um. defects, they had a higher incidence of fat
necrosis than other groups.
Peter Rubin did a series of experimental articles for fat grafting and um in the
Xenograph model, they also use ultrasonic liposuction rather than standard liposuction
for their, um, to obtain their fat and found that they produced the same amount of viable
cells. They were just more fatty, uh, fatty components
within that um aspirate than in standard techniques.
His second article was to see, depending on the cannula size and how much was injected
per uh per uh tunnel if that affected the fat survival
overall and what he found in this article was that smaller than a 14 gauge.
Injection, um, cannula and less than one cc per injection actually had a
higher um survival rate than larger because if you inject higher volume or you know with a
bigger cannula, it's actually too far from its source blood supply to be um viable.
When looking at the amount of fat to be injected to actually see a long-term results,
this article did 3D analysis to evaluate how much fat injected actually lasted and gave
a lasting result overall, and they showed that over time,
150 ccs or more injection actually lasted better and gave a better volumetric
sustainability than a smaller volume.
So here's um a bunch of fat that was prepared by active filtration.
I typically will put my graphs, my fat grafts into a 3 CC syringe and use my the MNS because
it has a smaller length of pushing and so I do a much lower Eliqua as
I'm injecting and that helps me with control as well as teaching residents how to inject it.
It makes it so that they don't use their thumb and just inject the whole three C's.
One big glob and cause a fatty cyst or fat necrosis.
I use the um Coleman cannulas and I put multiple access sites all over the breast and
then start injecting close to the surface to stay out of any um capsule.
I'll leave the implant in place or the tissue expander in place while I inject that allows me
to move the implant around and then I can actually.
Check the contour so that the areas that were in question um preoperatively are actually
filled so that when I do my capsul or or capsulotomy and implant placement or
replacement, then I can actually see what effect that fat grafting will have.
And so I like I said, I inject very close to the skin and I'll inject prior to removing it
as well so that especially with trainees you can um.
Discern whether or not fat's getting into the capsule because we want all that to be extra
capsular, so it's nice, especially early on, to show that you're not putting a bunch of fat
around the implant in the capsule, that your fat is going where you want the fat to go.
So I typically will leave whatever implant is in there while I'm injecting and then remove it
and wash out any debris that may have gotten into the capsule.
So this is a decades old early fat grafting for contour deformity and the rippling.
This was the handheld tha technique, and you can see that although there is an improvement,
you can tell that it's a much lower volume than some of the fat grafting in other patients.
This patient is um 6 months after 150 ccs to each breast reconstruction.
She felt that her breasts were not as big as they were preoperatively,
even though she had the largest implant that we had available and so she wanted extra volume
and got 150 ccs which made her feel um more like her normal self.
This is 6 months after um 80CCs per breast, and you can see here that the the upper pole
deformity and that kind of shelf is nicely camouflaged with ADCCs of that.
Those were all subpectoral um reconstructions.
This is a um subcutaneous reconstruction with, uh, in a,
um, a trainer.
So she lifts weights a tonne and um wanted a pre-pectoral um or subcutaneous.
It's not is it sorry, um.
The uh pre-pectoral or subcutaneous reconstruction.
So she has a pretty significant step off and with this is 6 weeks after 50 ccs to the breast.
And you can see here that she has an a natural contour um with a much better overall uh
reconstruction. So in conclusion, from the papers that um were
uh in this talk, donor site itself doesn't affect fat viability.
So, um you can take it from wherever they have fat available.
Active filtration actually gives the best volume and viability.
The um Telfaro has a smaller aqueous component, but it has a little bit more blood.
It's good for a very delicate area like under the eyes,
not necessarily so much usefulness in breast reconstruction.
Centrifugation actually results in more oil cysts.
Um, injection into breast conservation or a lumpectomy defect ends up running into a higher
rate of fat necrosis.
Slower injection rates tend to decrease trauma to the cells,
so the viability of the fat actually is better, and a smaller volume per pass and a smaller
cannula size actually improve viability as well just because of distance from the blood supply.
So back grafting overall is a great adjunctive um breast uh surgery and uh breast
reconstruction, um, and it's got a great, it's a natural alternative to the other materials.
Thank you.
And our next speaker is Phillip Stilart talking about lipofilling and nutrition.
Thank you very much. Good afternoon.
Um, I received an email from uh Marlene, and she asked me,
Philip, what are the topics you want to talk about?
And I said, it's um.
Everything about breast reconstruction, autologous or implant-based reconstruction,
and then I got an email back and she said, can you talk about lipofilling and nutrition?
I said, oh my God, lipofilling and nutrition.
So It's, it's the first time in my career that I have to give some kind of hypothetical
presentation, but actually it's a very interesting topic.
I am a temporary my disclosures that I'm a temporary consultant for establishment labs,
and it's a very interesting topic because um I've been thinking about that topic already for
a long time and if I ask my colleagues what do you do regarding food,
you know, after the fat grafting, most of them they say no,
we don't do anything special and I've been advising my patients the last couple of years,
you know, try to follow the Mediterranean diet, avocados, salmon,
uh, fish, nuts also, uh, which can be helpful, but it's all hypothetical.
It's very interesting and um you know that there are a lot of variables involved in fat
grafting, you know, the age donor side, the quality of the recipients site,
the processing technique, the harvesting technique.
There are so many variables that have an impact on your fat graft survival,
and I think food or nutrition, preoperatively and postoperatively could have an impact
in my opinion because If I go back to, I had a look at the literature and there was nothing I
could there was nothing to find about the impact of food on fat grafting in the plastic
surgery journals, but you do find some articles about the impact of food on wound healing,
and I think it should be the same for fat grafting because fat grafting,
what does it mean?
And you are relocating clusters of cells to another location and each cell
cluster. Has a unique micro architecture and I think
that the cell clusters with a high stromovascular flexion will have a higher
chance of survival because they release cytokines, they release molecules that will
stimulate angiogenesis.
The thing is with fat grafting, angiogenesis occurs after 72 hours,
so initially the immediate postoperative period they need to survive in a hypoxic environment,
so they have to drink plasma from the environment.
So these hypoxic cells, they absorb nutritions from the wound bed.
So and then um what I've been doing also is I when I uh lipofill an area,
I isolate some plasma from the patient and I enrich that recipisy
plasma because the idea behind the technique is that when you add some plasma,
you will have a better fat graft survival and I've been trying to prove this in vitro with an
in vitro study and where we put in a fat graph for 5 days in the patient's plasma and we
compare it to a culture medium like DMEM faecal serum, so the standard culture media,
and what did we see? We see, we saw that the fat graft survives for
5 days without.
The need of changing the media, so it was doing as well as good
as the DMEM and the foetal calcium.
So plasma, the stage of plasmatic inhibition is a really important stage in fat gras survival.
I think it's important when you perform a lipo filling procedure you have to consider two
things. First of all, you are actually putting the
patient's body in some kind of stress situation.
There is the trauma of the liposuction, and it's something we're not aware of often,
but liposuction.
It's actually a very traumatic event. You are disrupting that connective tissue,
which is your adipose tissue.
You do liposuction of the abdomen, the thighs, the love handle regions,
so it has quite an impact on the human body. So that body is already in stress.
And then you're asking that body that is already in stress also to support the survival
of the fat graft. So there are two things that you should
consider. You have to recover from the liposuction and
you have to support the fat graft survival.
And you know, fat graft survival, it happens through plasmatic inhibition,
the 1st 48 to 72 hours. And after that, because of the signals,
the hypoxic signals like uh HIP1 signals, for example.
You will have a stimulation of angio induction, and neovascularization occurs at approximately
1 millimetre a day.
So you have a body that is in stress. So what happens is that it releases a lot of,
uh, mainly inflammatory cytokines. It creates uh cortisol,
glucagon, adrenaline, and it has an impact on the healing potential,
the growing potential of, of the body.
And it will also impair the metabolism, the homeostatic metabolism.
So that's something that you should consider also in your lipofilling procedure and as the
surgically induced stress response typically consists of two phases.
There is the up phase that lasts for two days, and during the up phase,
you have the cardiac output that is decreased.
You have the oxygen. Consumption that is decreased.
You also have a lower metabolic rate of the body and the homeostasis and also there was
some kind of glucose intolerance.
After the two days, your body will try to recover and what's happening is you will,
um, the the the the tissues will get oxygenated again.
Your metabolism will increase and you will you come in some state of hyperglycemia.
So, um, Um, wound healing, so postoperatively, what is necessary in wound
healing, it is energy and proteins. So proteins are the building bricks in wound
healing, and the energy is needed for those processes, you know,
in the process of wound healing is based on the body needs enough energy,
and energy is mainly provided by uh fatty acids, for example,
by the fat. So, um, you have in mounting the inflammatory
phase, you have the pro the, the, the, the angiogenic phase where,
where everything is growing and, and, and is, is proliferating,
and then you have the remodelling phase.
So and regarding the food, so you have to advise your patients,
OK, you still need to, you need water before you need hydration,
you need vitamins, minerals, and then proteins also necessary because you have to counteract
the catabolism of the muscle.
And so that's very important. You have to avoid that your body is actually
extracting proteins from the muscle.
And also the fatty acids, they are also necessary to support the,
the, the, all the processes in, in the metabolism and that's mainly true for uh
adipose tissue. So we make a difference between the macro
nutritional needs and the micro nutritional needs.
So the micro nutritional needs are, for example, the carbohydrates,
the proteins, the fats and the fatty acids, but the micro
nutritional needs are all those like zinc, copper, selenium.
These are all small molecules that are the vitamins are involved in the processes of wound
healing. So, and, you know, I started to look at um um
all, all the functions and, and they are not only involved in specific processes but uh some
researchers have, have done some in vitro studies trying to study the uh Angiogenic and
the antiangiogenic properties of certain molecules in food and this is quite interesting
because um food that is antiangiogenic will be given to cancer patients,
for example, to counteract the growth of a tumour for example.
Olive oil, for example, has omega 3 poor poorly saturated fatty acids,
but olive oil, the oil and olive oil will inhibit angiogenesis.
So in theory you could tell your patient, OK, after a fat grafting session you shouldn't have
olive oil. And the omega 6 fatty acids, for example,
they are found in peanut oil, corn oil, sunflower oil.
And they have a uh a positive impact on endother cell migration.
So you could advise a patient, for example, postoperatively, you should have this specific
type of oils. Another thing that's interesting is,
um, so I mean acids that are involved in structural protein synthesis and then the
proteins for collagen development and collagen synthesis and um something very interesting is
the phenolic acid components. So the phenolic acid components,
they are actually involved in an Oxidant processes and anti-inflammatory processes,
and these are found in red wine, for example.
So you can advise your patient to have like for example, one glass of red wine postoperatively,
but you have to avoid coffee because coffee will have a delirious impact on the
inflammatory status of the body.
So there's so many different molecules that are involved in trying to prescribe a decent
diet to your patient.
And all the compounds in food, they act that are acting angiogenic on on an anti-angiogenic
activity, they they are inhibiting the endotenal cell migration.
They inhibit the tube formation and they have a bad impact on the VGF projection.
So all this kind of food should be avoided.
To make it more complicated, I'm not gonna mention all those names,
but you can see, for example, these are the compounds with anti-angiogenic activity.
So from a theoretical point of view, you should avoid them in the immediate postoperative
period. For example, greys, red wine, olive oil,
soybeans, capers, elderberries, strawberry, apple, kiwi,
fennel, parsley, broccoli, apple, and then coffee, spices,
rosemary, rhubarb.
These are all. Kind of food that you should avoid immediately
after a fat grafting procedure.
And there are two things before surgery you can prepare your patient and after surgery you take
care of the patient. So before surgery you should prevent that the
body becomes in some kind of inflammatory condition.
So you have to prevent inflammation. You have to boost the immune system
preoperatively. You have to eliminate all the anti-angiogenic
food, and the question is also what about hyperbaric oxygen?
I know some colleagues, mainly in the states, what do they do?
They sent the patient like a couple of weeks before surgery to the hyperbaric oxygen chamber
to actually boost the oxygenation of the tissues trying to enhance the survival rate of
the fat grass. After surgery, always prescribe your patient a
protein-rich diet, so to prevent that you that you will actually induce
muscle catabolism. So that's important.
Also try to prescribe an anti-inflammatory diet and in the 1st 72 hours from a
theoretical point of view, as I said, it's purely hypothetical.
Um, you actually prescribe an angiogenic diet because you need vessels,
uh, uh, sprouting of young vessels to support, uh, the survival of the fat and also
antioxidants should be should be prescribed.
For example, this case, um, I had to find a case and,
and this is quite an interesting case. This is a young patient,
breast implants. She came here.
I want to remove my breast implants.
Um, she, she, she's, she's very skinny, so there's not sufficient donut tissue,
so I moved the implants in the fat grafting procedure.
And I told her, you know, postoperatively we're going to try everything to enhance the survival
rate of the grafted fat, you know, try to to follow a diet that is rich of
avocados, oil, olive oil, you know, stay away from junk food because junk food creates an
inflammatory condition, stay away from coffee, you know.
Try to eat very healthy, and this is on the patient like this is 10 months later,
you know, and she's skinny and it's surprising to see that it's quite a good result.
I'm not saying it's because of the diet. I'm not sure because we know we need solid
scientific proof if it actually works. And so based on the data that I collected and
also. Based on some stories of patients, this is
actually a resume of everything. So one month before surgery,
I tell my patients now stay away from white bread, salt,
sugar, white rice, because these are foods that cause inflammation and will actually
also suppress your immune system a week before surgery.
You can actually delete all the foods that have an impact on the angiogenesis,
so that will suppress mainly angiopo in two.
So for example, ginger, garlic, tomato, omega 3 capsules compared to remember
omega 3 and.
6 omega 6 will actually support angiogenesis and that's why at day 2,
72 hours after surgery, you should give those oils.
So I advise them to eat fish, Greek yoghurt.
It's also important to do proteins, scrambled eggs and chicken balls,
for example, and then sunflower oil, cooking and sunflower oil,
peanut oil eat dark chocolate and fish.
And then one month after surgery you should have avocados,
berries, a lot of berries, blueberries, cranberries, strawberry,
grapes, and a glass of red wine a day is also not bad,
but you should avoid junk food and calcium supplementation because calcium tablets will
actually cause some kind of oxidation of your fat, so you should avoid.
The other thing is also you can prescribe preoperatively mainly some kind of booster,
which is juven, and juven is well known. Juven is uh has a specific um um um
proteins and, and, um, amino acids like arginine, also zinc,
vitamin C, E and B12, and then also there in the states you can buy heel fast and copper
or zinc or iron are also important and are involved in the angiogenic process and the
transport of oxygen.
So to conclude, I think it's still very hypothetical, but it's definitely worthwhile to
have a look into it, and I think specific nutraceuticals could be supportive in trying to
enhance the survival rate of your fat, and you should ma the immediate postoperative period
for 72 hours. You should focus on an angiogenic diet,
I think. You should focus on an anti-inflammatory diet
and an antioxidant diet, and I think it's one of those factors,
one of those variables that will actually help you in trying to enhance the survival rate of
your fat. Thank you very much.
OK, Doctor Rehnquist is our next speaker speaking about treatment of adverse
liposuction and lipofilling donor sites. How to correct.
You know, sometimes you're just lucky. I've been implementing this type of diet
restrictions for 12 years, but not for this reason, but because starting doing surgery in
Asia Pacific around 2005, I had a lot of bleeders.
They were oozing. So based on that, I'll start looking at what
type of diet they were having.
And of course, their diet is very much what you, it's good to hear,
so ginger, omega 3, fish, etc.
because it increased the oozing.
So, so I guess I've been lucky. Maybe that's one of the reasons why I'm,
I'm, I'm. Doing fairly well sometimes.
So, uh, and also I was assigned something uh uh 2017, I was here giving lectures on
tummy tucks and, and, and, um.
No insurgents some attacks, and since then I've not been speaking in this area,
but I have to say.
What this does, this lecture, it enables me, perfect, thank you.
It enables me to to touch something that I think is important because there is an
evolution right now, not just about Are we on?
No, we're not on, not, not just about.
The best way of transferring the fat, but also actually how to
do.
Lipo sculpturing, liposuction, and I have to say the Latin Americans are doing a great job.
Uh, I'm still not on so I can keep on talking.
OK, fine. So, so, so.
I remember when Coleman started talking about fat transfers,
you know, in the states east coast, and we started injecting.
And how we harvested fat and my topic will be about Some of the
things that can happen when you do harvest fat, but also what could happen when you transfer
fat. And we all know what happens when we transfer
fat to.
The history behind transferring fat to the butt, the Brazilian.
and the complications we've seen.
So with that said, harvesting fat and transferring transplantation of
fat is not harmless.
There are risks involved.
But the good thing about this is I do believe part of our future,
whether it's aesthetic or reconstructive, will be on fat transfers,
and I think it's going to grow more and more.
So we need to enable.
We need to know the different type of techniques there are out there to create good
lipo sculpture and good liposuction.
Otherwise we will have maybe a happy patient regarding the size of her breasts,
but she'll have a lot of Problems in the rest of the body with dimples and
unevenness, and that doesn't create a great environment for happy patients.
So with that said, within the last 3 years, I've actually,
I, I used to hate liposuction, one of the most boring procedures having Obese patients coming
into the office and and instead of Living what I would think may be healthier,
better life, they expected this to be some sort of fast diet.
And I really didn't like it.
I did it very often in combinations with tummy tucks, but in general,
no, I didn't do a lot of liposuction because I just thought it was boring and not very
aesthetic pleasing.
However, I have to say I've absolutely changed that opinion.
Today I enjoy doing lipo sculpturing and it's so much fun and I've really been
encouraged by my Latin.
Comrades, I mean they're doing amazing jobs right now and inspired by them.
And The whole procedure per se becomes so much more interesting for the patient because they
don't just have a more beautiful breasts, but in cooperation with the body it just looks
nicer. And if one does nice lipo sculpturing what
happens is that if you're able to to create that.
Beautiful figure, the breasts look bigger also, so it's a combo from a proportional thinking.
Maybe we'll skip the talk and I'll just talk.
Yeah, please do, whatever, whatever.
I don't mind. No, no, no, no problem.
On the contrary. So, so.
I don't need that. OK, so I'll move forward with that one,
yeah, yeah, sure, no problem.
So I'm actually enjoying lapo sculpturing a lot, and it's today the
fastest growing procedure within my facility.
And of course with all that fat harvest, I try to as
much as possible avoid implants using that fat, and I've been inspired
by speakers on this panel also how to move forward doing this better.
But I think with any breast practise being having a good aesthetic sense because that's
really what it boils down to having an aesthetic sense,
doing this lipo sculpturing, use that fat and harvest it.
And then inject it where it's needed.
Both in aesthetic and reconstructive.
So treatments of adverse liposuction.
Is this coming up only here or on these screens too?
Will I have them? Only here or
OK, how to avoid and correct.
No signal. Uh, and I can't click, I'm sorry guys.
Yeah, I'm, I'm click, oh, OK, now it's moving.
OK, good. So, Um This was my poor
lapo sculpting philosophy.
Many years ago I had some idea of how to do this, but I didn't have
this is 10 years ago. I didn't have the type of equipment that I have
today. So when I have these patients, I use this fat
in general, but in those times what I did, I did this type of lipo sculpturing and for
me, The best harvesting is really from the back area.
Why? Because the skin is thick and you can take a
lot, you create that waistline and the breasts look bigger,
and the risks of causing some unevenness are less.
So this is what I did. I used to put implants in and this is just a
typical tummy tuck.
And Just the average result that I used to have.
I didn't think about using the fat at that time.
Now, with fat transfers and and with harvesting the fat.
Trying to get fat out of out of small areas, these were the adverse effects I
saw discoloration, unevenness, scarring, necrosis, perforation,
embolism. And death.
I've not seen any death within my practise, luckily.
But I've had one embolism.
Um Without any further problem that she had to, and I
give these patients one of the things I do. I give them,
of course, anticoagulencia, and I try to treat them according to principles
at any big hospital, but these are really the risks that might occur.
Uh, or some of the risks.
And when you have these, these bigger patients, sometimes they have herniations,
they have weaknesses, and if you're not careful you might perforate and that is very sad if you
do, because that might cause a lot of harm.
So today with a lot of the techniques we see, which are more mechanical like parasys the
lipoplasty where you have the vibration, you have to be careful in these cases.
So one of the things that I learned shifting from so-called Vacuum assisted lipoplasty
to power assisted is that you really need to be on top of it and really feel exactly where you
are because the vibration takes away some of the sensation feeling you have for the tissue
when you're working with it. Now working with radio frequency and,
and a different type of um.
etching techniques, there are risks for necrosis.
One of the adverse things I've seen over time is it's very popular today to work with body
tight and other similar devices, and they come back and they're very uneven and they've just
had liposuction done and uneven as you try to go in there,
you try to do some type of tummy tuck procedure, you pull down,
you revise, you remove the scar tissue, and everything looks nice,
but they keep on oozing.
Not just 1 week, 2 weeks, 3 weeks, and they have a tendency to develop seromas.
And the reason for that, going back to what I did 20 years ago with ultrasound assisted
liposuctions, is I do believe that the heat induced does damage the lymph nodes and
the lymph drainage. I think we have issues there.
So in secondary cases of those who've had these type of heated procedures that are supposed to
shrink the tissue and assist you in that, be careful when you do secondary surgeries on them
and be careful if you do that in primary cases. I have all these devices,
and what I've learned is not to speed up things by inducing a lot of heat.
The killer ye yes, might be effective, but don't heat them up because you do damage the
tissue. So the treatment, how do we treat these adverse
liposuction, lipofilling donor sites? Well, secondary liposuction,
obviously if it's uneven, that's one way.
fat transfers, you've seen different ways of transferring the fat.
Em, LPG of course to soften the tissue and stimulate the lymph drainage and
the possibility of getting rid of toxic waste that's in there.
Belara for certain cases it is a nice way to melt the fat where you
think that the liposuction won't help them.
Revisions, of course, when there are necros, and your best friend is actually time.
Very often and I tell the patients you have to wait, whether it's my patient or if
it's someone else's.
Time is our best friend in these cases very often because the tissue softens and we know
that scar tissue softens up to 2 years.
So basically today, In these cases, even young women who come to me,
they've got nice bodies. They want to have the high definition lipo
sculpturing, and they say, yeah, I want to go bigger with breasts and with my butt.
I tell them, well, I recommend you fat.
And what I then do is Uh, I take them and I.
Make the drawings and I make the planning, where to put and the amounts and then I move
forward. So in this case um I put 210 ccs in her breasts
each side. And the 400 cc's in the buck reshaping.
And So once again, if you have an aesthetic sense and you like that
type of concepts creating, you can create a better harmony with the lapa sculpturing
and not having to put big implants in to create a waistline.
So in my practise, very often in these younger women, I really prefer to do this.
Um, and, and create a better harmony in the body without putting any implants in.
So the best way really to avoid Problems is using
a technique, go to someone that teaches you how to use them,
and I personally work today a lot with the power assisted lipoplasty,
and I use a basket tip 4 to 5 millimetres and using that
and wet dissection 1 to 1.
Really enables me even to etch and go under the skin without having unevenness.
So the best way to avoid problems is do it the right way the first time.
So today within my practise, like I said, in these cases,
creating the fullness, whether it's in the breast or in the butt,
combining it with high definition laro sculpturing has really changed the practise for
me, and I really enjoy it.
So in cases like this where I have a patient, I remove the implants,
which is part of a big part of my practise, secondary breast surgeries.
Unfortunately that comes with age, secondary procedures.
When I extract the implants and I put fat in, I put a smaller implant in.
I don't just inject the fat between the skin and the capsule
anteriorly. I also do the same thing posteriorly if they're
on the glandular, so I put fat on top of the muscle between the muscle and the
fascia, so I have lipo filling on both sides and then smaller implants.
Which actually gives quite a decent result with not too much fat.
So with that said, um, if you ever come to Stockholm, that's my clinic,
and some of you have been there, you're more than welcome to get in touch with me.
Thank you very much.
OK, the last speaker.
And it's gonna be.
Doctor Fabia, Flavia, yeah, she's gonna talk about non-surgical management of lapofilling
donor sites.
Thank you for the opportunity. I'm very, very honoured to be here.
So basically, uh, where's the control here?
So, um, I have no disclosures basically. I am Brazilian guys and I'm a little bit
nervous with my funny accent, and I hope you guys understand me.
So who I am, I am a physiotherapist, ah, the matter functional physiotherapist expert in
manual lymphatic drainage with over 13 years experience, um,
member of H HCPC and CSP, and I am creator of the recovery expert.
Ah, so I take care of some of your friends here in London and I also teach what what we
do. So, ah, according to the American Physiotherapy
Society, they, ah, launched a guide in 2001 saying that ah physiotherapists,
the matter functional physiotherapists are the ones looking after rehabilitating the
intermentary tissue.
So this is what we do.
So Taking that in consideration, the Brazilian Society of Plastic Surgery recommends that only
physiotherapists rehabilitate the intermentary tissue.
So what we do, we take care of the tissue. Yes, indeed,
as the colleague said, there is a lot of things happening there is heat,
there is a lot of mechanical tension, and we know exactly how to perform
and to. The donorcytes before it goes to the fat
transfer. So we take care of the we manage the pain and
inflammation. We prevent complications like fibrosis.
So guys, yes, it happens. It's not only taking care of the fat,
removing the fat. How about the donorcy?
What was left before there is a damage. Yes, there is a trauma to the tissue and the
faeces are there to rehabilitate that intermentary.
Oops, tissue.
I'm OK. Ah, so we, we do improve the, the, the surgical
outcomes because there is a lot of lumps left sometimes when ah the tissue doesn't rep out
doesn't recover properly.
So we reduce as well the, the patient down time. So I'm a little bit nervous with my English.
So what we do, ah, we work from the preoperative way,
we, ah, indeed prepared that tissue with oxygenation.
We prepare with energy and we prepare that patient to donate the the fat and to
get the fat there for longer as possible and then when we can with the when we have the
privileges of going to the theatre, we work immediately after the surgery and then in the
postoperative way.
So in the pre the preoperative approach, we do the skin assessments,
as was said here, there is a lot of adhesions, fibrosis, elastic Of elasticity and the
scars that can indeed lead to a ah not good outcome because the tissue tensions
are going to be affected, so we have to prepare that tissue to donate the best fat and then the
outcome is going to be the best one. We do the taping test,
I don't know how many of you guys now work with the taping,
the ssio elastic bonds for the donor sites and also to the receiving sites for the
fat. We work with the biomarkers.
We boost antioxidants and photobiomodulation, and we do the measurements for the
garments. It's quite common to receive patients in in my
in my room, in my clinical practise with very tight garments where there is a lack of
circulation and uh and nutrition to the tissue leading to seroma formation and
leading to fibrosis. And on the other hand,
sometimes. I get clients there with very loose garments,
which basically is doing nothing. So it's very important to have this
preoperative approach.
So when we have the privileges to go to the theatre, what we do,
we work with ah the extracellular matri mediators, oxygenating the tissue and avoiding
tissue ischemia, and also most of the times we can even avoid necrosis because we are giving
extra oxygen to the tissue.
So there's a lot of. that can be avoided by doing the immediate
approach. We do the containment with the tapings,
yes, there is different cuttings, different directions and different tensions on the
elastic band to give the results we are looking for.
Every patient is different. Every donator site has a different approach and
uh depending on the size of the surgery and how long is the patient there for,
ah, we need to decide which tension to put and which compression to use.
And the garments, we are the ones who, who packed the patient's back on.
So here is a study in Brazil where we have here the experimental group and the control group
where we used the taping straight after the surgery, same surgery,
same surgeon, and 4 days after the, the, the surgery, we have here the experimental group
using the tapings with little or very, very little bruise and edoema,
and the contour group, the difference is there showing for you.
Ah, here we have the second picture with the same, um,
the same results. We have the positive image for patients in the
experimental group 44 days later with very little edoema and very,
very little bruises, and in the other one we have the,
the same result as the first picture. So as bigger as is the edoema,
bigger is ah the is the different compounds in the tissue that will lead to fibrosis
formation. No other complications.
And this is the 3rd 1, ah, which shows the same results.
So using the taping here seems to be quite efficient to ah improve ah the,
the nutrients to the tissue.
So what the taping does mainly is like it is going to open up a space between the derms and
the derms, leading, leaving the the fluids to pass by.
So in the same time, we are going um mainly the, the paper says like after 30 minutes of the
taping application, the space between derms and epiderms is going to open up in 0.5.
After 6 hours of the taping placement, the space between derms and epiderms is going to
be 3 times bigger, so it allows the flow and we prevent the stagnation.
In the same time, we bring the oxygen and the nutrients to the to the to the tissue.
We also are eliminating the metabolic waste.
So what we do in the post phase, of course we have to identify which phase of the
postoperative period that client came to us because depending on the phase,
we are going to take the decision for the treatment plan.
Every phase is very different. There is a phase where we have a lot of edoema,
phases where we have a lot of proliferative cells, getting the tissue,
the surround the extracellular.
Mares very dense and when the extracellular matrices is very dense,
we can't give too much stimuli like a radiotherapy.
We don't use radiotherapy in this in this phase because we can overstimulate and overheal
this patient, so we have to identify which phase of the inflammatory process is this
client and then take the approach accordingly.
So, ah, we use a lot of the mechanical transduction because,
ah, the mechanical transduction has been studied for 15 years and it's knowing that ah
the, the energy you give to the skin, the top of the skin is going to result in different
Ah, a compound components on the extracellular matrix.
So if we give too much energy, if we give too much pressure to this tissue,
it's very likely that this tissue is going to overheal producing fibrosis and loyoids.
So here is one of the examples, as I said, when there is intrinsics and
intrinsic and extrinsic forces, we can change the cascade and that
will change the mechano responsive genes, which is going to change the mechanical transaction,
which is what is going to change your extracellular.
And that's what we operate from on the on the extracellular mug trees because if your
extracellular mug trees is alterated, this one is going to be dense and it is going to affect
the lyfangiogenesis and producing fibrosis.
And if there is fibrosis in here, I'm going to delay the lymph funiogenesis as well.
So it's so important to know that lymphatic drainage is not the only technique we use for
rehab this tissue and ah we ah indeed ah ah give like a lot
of responsibility to the, to the energy, to the stimuli you're giving to the donor sites
ah to prepare it in the proper way.
So here talking about fibrosis, which is the main main concern we have for after the,
the, the fat graft.
So, and, and yes, thank you Philip and the ah the colleague Philip and you that said,
yes, that's a lot of nutrients that we can avoid and we are going to be looking after it
to. Prevent all of those mediators that leads to
fibrosis. So here is mainly what we do by touching
manoeuvres, but not only lymphatic drainage because what is the point of only doing
lymphatic drainage in a stage where your your lymph androgenes is not ready yet?
Right? Are you all with me? Good.
So here we have, we are going to be operating here, um,
avoiding the oxidative stress with a lot of techniques and um also controlling the
glycemic load, so very important. So we see here are some of the techniques we
use, not only lymphatic drainage, but we, we use the mechano modulatory manoeuvres,
the taping, which is fantastic for me, the keypads and appropriated garments,
the photobiomodulation giving. The the mitochondris,
the right energy in the right phase of the recovery, it's not,
it's not like we see people using machines but they don't know how to calculate how much
energy I can give to this tissue in this phase. So it's very important to know what are you
doing? Are you stimulating?
Does this client need stimulation or uh I can really overstimulate this client,
so. Every patient is very unique and the approach
must be very tailored.
We use the photobiomodulation a lot on topic and also on the radio,
on the radial vessels where we can give extra energy to the blood cells and go and repair the
tissue and lymphatic drainage, yes, is indeed one of our techniques.
And you guys, have you ever heard of ozone therapy for plastic surgeries?
Yeah, it's quite big in Brazil and there is a lot of studies suggesting ozone therapy for pre
intra and post-operative care.
Uh, here are some of the mecanotherapeutic manoeuvres.
Uh, they are all different of lymphatic drainage.
Sometimes, um, uh, I got a lot of data. my surgeon,
uh, suggested me to find you for lymphatic drainage.
Yes, we are going to be doing lymphatic drainage, but not only lymphatic drainage,
so there's a lot. More involved.
So once we understand the vectors of forces that it's acting on the
tissue, we can actually decide what we're going to be doing to treat this tissue.
So this is a donor site full of fibrosis.
I don't know if I can play this video.
It's a little bigger. Ah, the first one is not playing,
which was this one. So this is a donor site.
This is a type of technique we are using, ah, to Yeah,
there we go. As you can see, this person came with an
inflammation and there is a lot of lump lumps and bumps.
Um, then we are performing this one at the back, lymphatic drainage.
So it might seem the same for you guys, but for a physiotherapy that touches the skin and feels
the difference, ah, it makes a lot of difference on the results.
So here are the donor sites, what we do with the taping.
So depending on the area, depending on how deep and depending on the time we see the
client, we decide which direction, which cut, and how many tension we are going
to be putting on the elastic band, and that will prevent that will release the
tension. On the tissue avoiding the fibrosis,
which is very, very good.
So we have lots of places for donors signs, and this is a lovely one.
I love this picture because we had the opportunity to go in theatre and place this
taping in a very different way that we saw before and here after 4 days there is no
bruises, so it really works.
Here is an example of the photobiomodulation that we use.
We use it as Eli, which is intravenous laser irradiation of blood,
and also we use it topically. Uh, we can use infrared and red lights,
and they can be different sources of energy, so we decided
when we assess the clients.
Accordingly to the client's needs.
And this is Be used very, very much so. This is one example of ah
ozone therapy for nipple necrosis and um Yeah, we have a few
good examples. We can actually oxygenate the tissue again.
Ah, because ozone is a molecule, ah, it's very stable molecule of oxygen,
so it stays as an ozone only for 10 minutes. After 10 minutes,
it becomes again uh medical oxygen. So this tissue can be well,
well, ah, oxygenated and come back to what it supposed to be.
So we can repair, we can recover, we can rehab, ah the tissue to its normal function.
Here, uh, it's one of the before and afters we've been working,
59:56.500 --> 01:00:01.469 uh, this, this patient, she saw 12 therapists come to us.
01:00:01.760 --> 01:00:08.590 It was after a year of, um, uh, uh liposuction, and this is what
01:00:08.590 --> 01:00:12.310 we could do with the techniques we use, and this is another one,
01:00:12.560 --> 01:00:16.209 and this is how she left us after.
01:00:17.360 --> 01:00:20.189 Let's say 2 weeks, and here we go.
01:00:20.399 --> 01:00:21.530 Thank you so much.
01:00:29.179 --> 01:00:33.889 OK, so I think we heard very interesting and nice presentations.
01:00:34.669 --> 01:00:40.020 I do have several questions for the speakers, but I wonder if anybody from the audience has a,
01:00:40.139 --> 01:00:41.169 a question for them.
01:00:42.860 --> 01:00:44.850 Yes, please. Can we give a microphone for him?
01:00:51.389 --> 01:00:53.050 Hello Dick from Germany.
01:00:53.469 --> 01:00:57.060 I have very bad experience with um the tapes.
01:00:57.300 --> 01:01:00.610 First of all, thank you very much all of you for your great speeches.
01:01:00.899 --> 01:01:07.709 I have, I have very bad experience with tapes, um, because I saw a lot of um epidemiolysis,
01:01:08.139 --> 01:01:12.129 so the swelling comes from the beneath and the skin cannot move forward.
01:01:12.379 --> 01:01:15.010 Does any one of you see different things?
01:01:15.469 --> 01:01:19.050 And I couldn't get your question. Could you?
01:01:19.419 --> 01:01:23.370 Yeah, if you, if you put tapes directly at the end of the operation,
01:01:23.479 --> 01:01:25.629 it's before the swelling takes place.
01:01:25.959 --> 01:01:30.179 So when the swelling takes place and the skin is fixed under the tape.
01:01:30.540 --> 01:01:34.290 Then it can rupture from the place it was to be.
01:01:34.620 --> 01:01:41.459 And so this tape has either to be very soft and go with it or it it
01:01:41.459 --> 01:01:44.290 there's a different kind of structure. I mean,
01:01:44.340 --> 01:01:50.409 I use a different um liposuction technique. I use body jet and body jet has very few
01:01:50.409 --> 01:01:56.610 swelling, so we don't see a lot of epitheliallysis, but sometimes I've seen it,
01:01:56.790 --> 01:01:59.300 um, and when I saw others.
01:01:59.689 --> 01:02:06.659 And patients get always very unhappy when they have these huge bladders under the plasters
01:02:06.659 --> 01:02:11.010 and so, but I don't know if kinesio tape is lax enough to go with it.
01:02:11.260 --> 01:02:13.449 Yeah, thanks for your question. Very interesting.
01:02:13.540 --> 01:02:19.929 As I said, we have to assess the tissue first and then understand which tension we are going
01:02:19.929 --> 01:02:22.570 to put on that specific area.
01:02:22.810 --> 01:02:27.364 It's not the same. is not the same tension, so we need to assess
01:02:27.695 --> 01:02:32.504 what is going to be the mechanical tension for the recovery of that tissue.
01:02:34.215 --> 01:02:38.534 So it's not just cutting in place. We need to assess how the tissue is going to
01:02:38.534 --> 01:02:44.274 take that tension to avoid the vectors that causes fibrosis.
01:02:45.280 --> 01:02:49.500 And another question to Philip Stiller, thank you very much.
01:02:50.189 --> 01:02:56.250 I think we spoke in Bangkok about the idea of reducing weight before a lipo transfer.
01:02:56.780 --> 01:03:02.510 Um this is something I tell my patients. I ask them to reduce their weight like 2 kg in
01:03:02.510 --> 01:03:09.159 the weeks before the operation, um, with the idea to reduce the size of the fat cells
01:03:09.429 --> 01:03:13.070 so that I can transplant more cells in the same volume.
01:03:13.550 --> 01:03:19.719 And then gain weight afterwards so that they shall, um,
01:03:20.010 --> 01:03:21.560 yeah, feed their cells.
01:03:21.889 --> 01:03:26.199 But I didn't think about telling them what to eat, just to eat.
01:03:26.770 --> 01:03:31.429 But as we know, often liposuction is the start of a diet.
01:03:31.729 --> 01:03:38.449 So many people say, now I did this, so now I'm gonna diet and reduce weight even
01:03:38.449 --> 01:03:39.479 more so.
01:03:39.929 --> 01:03:44.600 Maybe this is also an idea to bring into an an idea like that.
01:03:45.449 --> 01:03:46.659 Thank you very much. It was great.
01:03:46.810 --> 01:03:49.649 I, I had to take all the pictures.
01:03:50.879 --> 01:03:52.389 I have a question for you, Alana.
01:03:52.939 --> 01:03:58.899 There's some controversy about the combination of liokine together with fat grafting that
01:03:58.899 --> 01:04:00.649 reduces the takeoff of the fat.
01:04:00.899 --> 01:04:02.060 Any comments on this?
01:04:02.669 --> 01:04:07.290 I have not avoided the lidocaine. I use a standard Klein solution,
01:04:07.629 --> 01:04:11.449 um, and I'll use up to 3 litres of Klein's and then switch to,
01:04:11.620 --> 01:04:15.770 um, just, uh, lactated ringers with Epi after that.
01:04:16.020 --> 01:04:18.889 I haven't really seen that it's had a great effect.
01:04:19.260 --> 01:04:23.699 Well, you use the revolver, I see, and with the revolve, you're washing.
01:04:24.100 --> 01:04:29.899 We do 3 washes with ringers, so the thought is, is that you're washing a lot of that lidocaine
01:04:29.899 --> 01:04:34.409 out. What about any strategy for for patients with
01:04:34.409 --> 01:04:39.280 radiotherapy injury where you're gonna do some type of fillings different than you do.
01:04:39.530 --> 01:04:44.489 So I'll typically do a small volume at first just to kind of release the skin and get a
01:04:44.489 --> 01:04:50.449 little bit of a scaffold, a natural scaffold in between, and then plan to go for a larger
01:04:50.449 --> 01:04:52.800 volume in the second or third time.
01:04:53.280 --> 01:04:58.810 Those patients typically will need 3 times just because I do sort of try to release that with a
01:04:58.810 --> 01:05:01.260 small volume and allow that to be viable.
01:05:01.550 --> 01:05:05.020 It improves the quality of the skin with the growth factors that are in the fat,
01:05:05.229 --> 01:05:08.600 and then that allows for more stretch in the second procedure.
01:05:09.459 --> 01:05:15.010 Good. Charles, do you have any comments about people
01:05:15.010 --> 01:05:19.520 who are injecting fat into the muscle directly when they do an explantation?
01:05:19.729 --> 01:05:22.199 This is something that's been described recently also.
01:05:22.610 --> 01:05:24.770 You do the same. You mentioned that you put it on top of the
01:05:24.770 --> 01:05:26.929 muscle, yeah, between the muscle and the fascia.
01:05:27.250 --> 01:05:29.129 I'm a little bit afraid learning from the.
01:05:30.060 --> 01:05:36.260 Brazilian butt lifts, I mean, when you do that immediately you've got pretty big perforators
01:05:36.659 --> 01:05:42.860 and it's just one of those fears I have doing that, so I'm avoiding injecting in general and
01:05:42.860 --> 01:05:46.409 into the muscle being scared of having an adverse effect.
01:05:46.739 --> 01:05:50.909 One is enough. In these cases, there's something I'd like to
01:05:50.909 --> 01:05:56.729 add that I, I forgot which has been very, very good in my practise solving problems PRP.
01:05:58.100 --> 01:06:02.929 I mean, it's, it's, it's a great tool with these uh fibrotic and,
01:06:03.000 --> 01:06:04.159 and areas.
01:06:04.899 --> 01:06:06.850 It's really one of the number one things.
01:06:07.139 --> 01:06:11.870 And the second thing that I've added, but I'm mentioning it now.
01:06:12.209 --> 01:06:16.610 We're going to do a study on red light and post-op inflammatory reactions.
01:06:16.729 --> 01:06:20.790 So we have patients we've been waiting to have really good equipment so that patients can
01:06:20.790 --> 01:06:25.209 stand and we'll have red light, and I do believe that anything that brings down the
01:06:25.209 --> 01:06:26.409 inflammatory process.
01:06:26.939 --> 01:06:33.040 And healthy healing will be good in these cases because these are big operations that I'm doing
01:06:33.040 --> 01:06:39.590 now with lipo sculpturing and combining it with fat transfer so that's something that I've
01:06:39.590 --> 01:06:43.919 incorporated and we're also getting an oxygen pressure chamber.
01:06:47.110 --> 01:06:50.370 Yes, Philip, I have a lot of patients coming in now.
01:06:50.449 --> 01:06:57.449 We have a large explant population in the states and so they want to explant and use fat
01:06:57.449 --> 01:07:00.830 grafting. Instead, a lot of these patients are quite slim,
01:07:01.209 --> 01:07:05.199 and they ask me, should I gain weight before the procedure.
01:07:06.080 --> 01:07:10.020 What would you tell them? And if so, what foods would you recommend
01:07:10.020 --> 01:07:15.590 because I noticed a lot of your high caloric foods are on your banned list.
01:07:16.239 --> 01:07:19.790 It's, it's always annoying question because if they gain weight they will lose weight
01:07:19.790 --> 01:07:24.500 afterwards and the the thing is that um everybody's born with the same number of fat
01:07:24.500 --> 01:07:27.120 cells, you know, if you're gaining weight.
01:07:27.919 --> 01:07:31.669 just increasing the size of the cells. The amount of cells will not increase.
01:07:32.280 --> 01:07:34.790 It will just be easier to harvest the fat.
01:07:35.439 --> 01:07:38.389 That's the only difference, but the only problem is afterwards,
01:07:38.439 --> 01:07:41.800 you know, ask them to gain weight, then they say, OK,
01:07:41.879 --> 01:07:43.229 no one will lose weight again, so.
01:07:44.510 --> 01:07:46.949 What I would do is I, I would do the life fulfilling.
01:07:48.350 --> 01:07:51.429 When they have their normal weight, you know, because otherwise you would have too much
01:07:51.429 --> 01:07:57.179 fluctuation and tell them really that you know, the result will not be optimal,
01:07:57.320 --> 01:08:00.659 you know. Because we can't still, you know.
01:08:01.989 --> 01:08:05.879 Take out of the fridge. Another question for you.
01:08:05.889 --> 01:08:10.540 You say you're using plasma, which I assume is PRP that you're putting in with your fat grafts.
01:08:10.620 --> 01:08:12.290 No, no, just plasma.
01:08:12.820 --> 01:08:14.409 How are you getting your plasma?
01:08:14.780 --> 01:08:17.180 Just take a blood sample from the patient. I had a bit of heparin.
01:08:17.220 --> 01:08:23.410 I centrifuge and just take out the plasma the PRPs is that you always have really small
01:08:23.410 --> 01:08:27.410 volumes. a lot of blood and you obtain a really small
01:08:27.410 --> 01:08:29.120 volume. So and that's my question.
01:08:29.169 --> 01:08:32.919 What is your ratio of plasma to fat grafts that you use?
01:08:33.339 --> 01:08:35.220 It's about.
01:08:38.559 --> 01:08:44.899 40% Do you mix it all together and inject it?
01:08:45.240 --> 01:08:47.810 No, I just, I just, you know, we have the tubes.
01:08:48.229 --> 01:08:54.740 You ask theiologist to take a sample of blood like a syringe of 50 cc put in 10 cc
01:08:54.740 --> 01:09:01.069 syringes, centrifuge, and you aspirate the plasma in one syringe and then you can actually
01:09:01.359 --> 01:09:07.939 you don't need that much, you know, so your ratio of your plasma to your fat graft 1 to
01:09:07.939 --> 01:09:14.459 1. What I do, I perform my fat grafting procedure
01:09:14.990 --> 01:09:18.160 until I have a critical and then I add just a little bit of plasma,
01:09:18.229 --> 01:09:22.939 so there's not actually quite a ratio and I think that's too difficult to calculate.
01:09:23.740 --> 01:09:29.140 It's just you know the idea that adding a bit of something to help give them like a backpack
01:09:29.140 --> 01:09:35.899 with nutritions to help them overcome that initial postoperative hypoxic period.
01:09:36.189 --> 01:09:40.000 That's the only thing. They probably be very anaemic if you do 1 to 1
01:09:40.000 --> 01:09:41.000 ratio. That's true.
01:09:46.759 --> 01:09:50.600 That's true and Ilana, um, especially with your cancer patients,
01:09:50.680 --> 01:09:53.149 how are you managing fat necrosis in these patients?
01:09:53.160 --> 01:09:57.319 They come in, they feel lumps from, um, non-viable transfer.
01:09:57.399 --> 01:09:59.359 How are you, how are you handling them?
01:10:00.009 --> 01:10:05.830 So depending on the size of the area, um, if it's early in there.
01:10:06.819 --> 01:10:13.240 In their fat grafting, we know that it's we're not concerned that it's a new tumour because
01:10:13.240 --> 01:10:14.990 that's always a concern.
01:10:16.240 --> 01:10:19.549 A lot of times I'll either aspirate it when I do the next fat graft.
01:10:19.759 --> 01:10:23.640 Sometimes I'll make an incision and just remove that through a really small incision,
01:10:23.720 --> 01:10:24.799 kind of like a lipoma.
01:10:26.399 --> 01:10:31.629 If it's in like a deep flap or the edge of the deep flap,
01:10:31.839 --> 01:10:35.959 then I'll typically just graft over it and camouflage if it's small.
01:10:38.140 --> 01:10:39.839 Um, and then Flavia.
01:10:40.689 --> 01:10:43.750 You only leave those tapes on for 4 days.
01:10:44.000 --> 01:10:49.240 Do you replace them at all? OK, so how long do you actually keep them taped?
01:10:49.490 --> 01:10:53.709 So we have again to assess the patient and see the patient's needs.
01:10:54.000 --> 01:10:59.060 If I want to avoid the edoema and fibrosis formation in the first step,
01:10:59.319 --> 01:11:05.879 I will leave it for 4 days and then reassess. So if there is still um a possibility of
01:11:05.879 --> 01:11:09.600 fibrosis formation, uh, we'll replace the taping, but I will.
01:11:09.794 --> 01:11:13.104 Modify the tension and the cut and the directions.
01:11:13.754 --> 01:11:18.194 Sometimes even with the tapings, depending on the fibrosis mediators,
01:11:18.234 --> 01:11:21.944 that's why every patient is so unique.
01:11:23.435 --> 01:11:30.075 We still have appearance of few nodules of fibrosis, so we still have to put the tapings
01:11:30.075 --> 01:11:36.685 for for longer periods, but then we change it and see how it's the
01:11:36.685 --> 01:11:38.634 tension of the tissue is moving.
01:11:40.979 --> 01:11:42.990 I, I, I have a question for Flavia, um.
01:11:45.069 --> 01:11:48.069 If you don't have access to all those high tech techniques, you know,
01:11:48.220 --> 01:11:49.419 what is the basic?
01:11:49.740 --> 01:11:52.080 You know, because the patients they come to me and say,
01:11:52.490 --> 01:11:56.089 what size of garment do I need to order? I say I have no idea.
01:11:56.250 --> 01:11:57.819 No, medium, small, large.
01:11:58.100 --> 01:12:03.560 So is there is there any point that they put on or they measure the garment after the surgery
01:12:03.560 --> 01:12:07.560 or you have to put it on immediately? Why immediately?
01:12:07.970 --> 01:12:12.640 Because if you avoid the compression, if you avoid the edoema on that site,
01:12:12.970 --> 01:12:15.629 you're going to avoid the fibrosis formation.
01:12:15.890 --> 01:12:18.330 So the right size of garment is very.
01:12:19.222 --> 01:12:24.901 Because if it's too tight, as I said, you can suppress the nutrients for that you know the
01:12:24.901 --> 01:12:29.001 size you're going to measure your patient before she comes to the surgery,
01:12:29.102 --> 01:12:33.611 but she's going to be smaller, but you know how much fat you're going to take out,
01:12:33.742 --> 01:12:38.291 don't you? You you have an average of, of, of reduction.
01:12:38.301 --> 01:12:40.291 You're going to deliver to that patient.
01:12:40.501 --> 01:12:46.182 So you calculated before so not to be too tight because I've seen lots of like very,
01:12:46.222 --> 01:12:50.914 very, very tight. Garments leading to a lot of seroma because
01:12:50.914 --> 01:12:52.463 there is nowhere to drain.
01:12:52.784 --> 01:12:57.483 And when do you start your massage afterwards straight after.
01:12:57.644 --> 01:13:02.233 Like if I can have the privilege of going to the theatre like this,
01:13:02.394 --> 01:13:09.043 I have the privilege to work with some of you guys here and I have no complications and no
01:13:09.043 --> 01:13:14.954 complications like there is no seroma, there is no fibrosis,
01:13:15.074 --> 01:13:18.166 there is no complications. And for how long do you advise the garment?
01:13:18.326 --> 01:13:23.085 The garment I follow the doctors, the surgeons advices, but normally 6 weeks.
01:13:23.125 --> 01:13:28.556 I don't let them take it off less than 6 weeks unless the recovery is perfect.
01:13:28.605 --> 01:13:34.616 So in a normal setting garments 6 weeks and keypads
01:13:34.616 --> 01:13:37.275 keypads, please keypads.
01:13:37.666 --> 01:13:44.525 And another thing, it's important, very good to, to mention is uh the zippers to cloth.
01:13:44.667 --> 01:13:51.647 The garments, guys, some of the times you work for the for the graft on the love handles on
01:13:51.647 --> 01:13:58.047 the sides and the zipper go on top of the treated area so that changed completely the
01:13:58.498 --> 01:14:04.288 the mechanical tension of the healing tissue and that will form fibrosis.
01:14:04.788 --> 01:14:09.047 So I don't know, I think it was you who mentioned that you loved to to do the
01:14:09.047 --> 01:14:12.357 liposuction on the sides because they are thicker skin.
01:14:12.417 --> 01:14:15.950 Yes, indeed. Yes, indeed they are thicker, and that's why we
01:14:15.950 --> 01:14:19.430 have, we are more prone to develop fibrosis in that site.
01:14:19.799 --> 01:14:26.680 So the keypads, 360 good garments, right size garments are going to make a huge
01:14:26.680 --> 01:14:29.390 difference. So Flavia, may I make a comment.
01:14:29.720 --> 01:14:33.919 So basically you're recommending, so if one doesn't do manual,
01:14:34.129 --> 01:14:37.470 according to Doctor Vodler or whatever, and we're using endermology,
01:14:37.560 --> 01:14:41.250 LPG. Are you saying that you would recommend that
01:14:41.250 --> 01:14:42.839 early on, like the first day?
01:14:43.250 --> 01:14:49.649 I wouldn't recommend enymology early on at all because that will overstimulate the
01:14:49.649 --> 01:14:52.959 collagen production. The lymphangiogenes is not ready yet.
01:14:53.129 --> 01:14:57.169 No precisely. So that's why I'm sorry, yeah,
01:14:57.649 --> 01:15:01.609 because that's my point. So if one doesn't have someone doing it
01:15:01.609 --> 01:15:04.359 manually. Yes, what would you recommend?
01:15:04.680 --> 01:15:07.799 So doing lymphatic training manually if they don't know,
01:15:08.040 --> 01:15:11.479 no, no, not manually. If you have just a machine,
01:15:11.560 --> 01:15:14.839 a machine, a machine. We're talking about machines,
01:15:14.879 --> 01:15:18.589 OK, because I am manual lymphatic.
01:15:18.959 --> 01:15:24.189 I wish everyone would do manual, but you know, reality is if you go for machine,
01:15:24.240 --> 01:15:26.669 I would, I would say pressotherapy.
01:15:27.479 --> 01:15:33.950 To start from the pressotherapy that would spread the edoema from that side,
01:15:34.640 --> 01:15:41.589 allowing other lymph vessels to extract that excess fluid and get
01:15:41.589 --> 01:15:48.509 it back to myself, I'm sorry, I'm not clear obviously if you have endermology LPG,
01:15:49.000 --> 01:15:52.919 that's the device which a lot of people work with pre and post op.
01:15:53.359 --> 01:15:56.509 When would you recommend to have the treatment post op?
01:15:57.520 --> 01:16:04.189 6 weeks later, 6 weeks, because that's very interesting because after 10 days.
01:16:04.839 --> 01:16:06.390 That's why I'm asking this question.
01:16:06.640 --> 01:16:08.209 So you're saying 6 weeks.
01:16:08.600 --> 01:16:11.350 Sorry for pushing this based on what?
01:16:11.759 --> 01:16:16.310 Yeah, if you see, if you understand the mechanical tensions on the tissue,
01:16:16.600 --> 01:16:22.520 you're going to see that you still can stimulate the fibrosis formation after the the
01:16:22.520 --> 01:16:23.819 certain periods of time.
01:16:24.120 --> 01:16:26.950 So that's why I don't recommend it any earlier.
01:16:27.629 --> 01:16:32.649 OK. 6 weeks to 14 days.
01:16:32.950 --> 01:16:39.220 No, not frequency is the same entomology, I understand.
01:16:39.779 --> 01:16:45.140 But if you go to the concept of entomology, if I'm talking about the same machine,
01:16:45.220 --> 01:16:51.589 the same device as you, you're going to wear a suit and something is going to Make
01:16:51.589 --> 01:16:57.279 negative pressure, negative pressure, change the mechanical tensions inside of your tissue
01:16:57.589 --> 01:17:02.310 and push it all the way and you don't even know. The machine doesn't know where the lymphatic
01:17:02.310 --> 01:17:03.339 pathways are.
01:17:03.669 --> 01:17:07.830 So you're just going to change the tension and push it somewhere but hopefully the person
01:17:07.830 --> 01:17:09.189 knows the lymphatic pathway.
01:17:09.430 --> 01:17:12.950 Yeah, you can't be so precise with a machine. I'm sorry.
01:17:14.399 --> 01:17:21.109 OK. Is there, is there any other You what?
01:17:22.270 --> 01:17:24.879 Any other questions from the audience before we close the session?
01:17:26.339 --> 01:17:28.430 Otherwise I think we're on time.
01:17:28.779 --> 01:17:31.220 Once again, thank you very much for your nice presentations.
01:17:31.379 --> 01:17:31.890 Very good.