We will start now. The session advances and refinements of implant
reconstruction. And I want to announce our first speaker,
Andrea Morera.
She will talk about unilateral breast reconstruction, technical strategies for
symmetry. Good morning.
I'm so happy to be here. Thank you so much for the invitation.
This is a tough topic, so I hope I can do it in 10 minutes.
So, um, if you really look at statistics in the US, there's about almost 300,000 patients who
were diagnosed with breast cancer in the last year, and when you look at those patients,
about 30% will have mastectomies, and about 40% of the patients who will have mastectomies will
undergo reconstruction and it's still 2/3 of the patients who undergo mastectomy,
it's a unilateral mastectomy, um, so we need to be able to reconstruct these patients and give
them a good outcome. Um, we know that satisfaction after mastectomy
reconstruction is associated with autogenous reconstruction, full disclosure.
That's my preferred method to reconstruct a unilateral case.
Bilateral reconstruction, revision with grafting the all increased satisfaction for
these patients, unilateral reconstruction, radiation.
Complications will affect satisfaction for sure, and there are several challenges in achieving
a good reconstruction with unilateral mastectomy with implants.
First one is the natural symmetry of the breast. Breasts are sometimes not symmetrical.
There is the impact of surgery, radiation, ageing.
Weight gain over time, patients factors, skin quality is something that we cannot control,
and of course patients' expectations.
So I'm gonna divide my talk in two different topics.
One is the unilateral mastectomy and then the procedures that we do for the contralateral
breasts. Um, in my mind, there are some things that are
really important to consider.
First one, the breast characteristics. You have to look at the volume of the breast,
the width of this breast, and the degree of breasttosis, um,
the type of mastectomy that's going to be done, um, the pocket that you're going to have for
that implant, you need to be able to control the pocket if you want to get a good outcome,
and uh the implant characteristics. Unfortunately in US for my breast cancer
patients, I use smooth implants and I've seen these amazing talks with text implants that
That's not what we, we get, so it's always smooth implants.
Um, in terms of breast characteristics to me, what is really important is actually the
position of the breast on the chest wall, the breast base,
it's very important if you're gonna choose an implant, and you have to correlate that with
the contralateral breast.
The degree of doses that we see in some of these patients and of course the projection
also um of the breast. You need to be able to um.
To use your contralateral breast um to match all these characteristics.
Um, I think the type of mastectomy really matters.
Um, in general, nipple perimastectomies will give you a better outcome because it keeps the
projection of the breast because the nipple is the focal point of the breast.
Traditional skin sparing mastectomies, in my mind are the worst that you can do because you
take the nipple and you take the.
and you create an area of flatness on the central breast.
It's really difficult to fix that textured implants and shaped implants work really well
for that, but smooth implants, they actually don't work as well for that.
Um, wide span and reduction is great when you have a,
um, very large stoic breasts, and I would like to introduce a real sparing mastectomy because.
I think um they work extremely well.
So these are different types of incisions that can be used for niposparing mastectomies for a
real sparing, particularly if you're doing a unilateral case,
um, you know, you have the benefits of keeping somewhat the projection of the breast,
and this is just a demonstration. This lady, of course,
is a very small areola, so in this case the whole area was resected.
But many times we just take the areola and the mastectomy is done through the inframammary
fold. Of course we want to keep the me um the costs
of perforator intact if you can, um, and you can do that procedure.
It's safe oncologically. A lot of the data comes from Japan,
um, but it's a great option for unilateral reconstruction, so you don't lose as much the
projection of the breast.
Just to show you an example, this is a lady, this is a bilateral case,
but it's in a real bearing on the right side and you can't really see much of a difference,
so it's a good way to do it.
Now I think implant pocket really matters um for unilateral reconstruction,
uh, for bilateral, you can argue that you can go prepe to pack,
but for unilateral, you will see changes over time, um,
that will affect the symmetry of the breasts. First thing that we see is this um.
Oh, can you guys, yeah, you see the superior, um, displacement of the implant,
whereas the contralateral breast tends to have a more natural shape,
and over time if they gain weight, this breast is gonna drop and that one is gonna continue to
be high. So you know, these patients are going to have
more revisions. It's just a story that we see with some
muscular implants um in the lateral reconstruction.
And of course this is. Worse with radiation.
This is actually one of my patients.
She had a previous lumpectomy and radiation to this breast,
had a niposparing mastectomy and an implant and a reduction of the contralateral side.
You see the difference over time.
So I ended up took, I took her back to surgery. She ended up having an autogenous
reconstruction because I couldn't I realised that I wouldn't be able to do a good job if I
didn't change the, the, you know, the technique.
Um, instead of a submuscular implant, I do prefer a prepectoral implant.
I think it gives you better symmetry over time.
For patients who have a contralateral breast that is a little phoic using AGM um will
help because the AGM. We we stretch a little bit of our time and kind
of recreate some of that ptosis.
Um, I do an anterior wrap and for patients who have tighter chest,
I like before HB much better, um, and I think the complication rate with it,
it's, it's, it's much better than, uh, with AGMs.
The implant choice matters um in my mind what you have to,
you have to look at the patients in all different positions um many times you ask your
patient to lay down in the office and you see a very lateralized implant so you have to be able
to control the implant pocket as much as you can and the implants that you.
Choose for that unilateral reconstruction needs to match the base of the contralateral breast
and if you cannot achieve that with only an implant, maybe adding some fat grafting later
will help you to achieve that.
The other thing you have to pay attention is the projection of that implant that needs to
match the projection of the contralateral breast, and that's very difficult to do.
Um, just to show a case, this is actually a bilateral case and it was one of my last cases
with a form stable implant, um, and I just showed it to kind of show the markings.
I make sure that I mark the medial breast border so that's not violating the lateral
breast border. Um, I do use scisors.
I use saline scisors for my direct to implant, um, reconstruction.
I do an anterior wrap in this case was ageing.
Um, um, I do use nitro paste on the nipples. That is one of the only studies that show that
there is an evidence that using nitro paste at the time of surgery you can improve the,
the perfusion of the nipple, and I like toy foam to kind of shape the breasts.
Um, this lady had a um.
You know, lymph node dissection on the left side, and you can see even on the same patient,
these are two different mastectomies. They're two different breast procedures.
So I know that over time I'm gonna have to um to do some fat grafting to fix the other side
because it's gonna be radiated.
Now for the contralateral breast um.
There are different things you have to consider.
Uh, one of them, if the patient needs a reduction or a mastopexy,
um, there's a really good study by DBAio, and he actually evaluated patients who underwent
contralateral procedures with a superior superioredoppedicle as well as an inferior
particle, and what he was, he was able to find is that superior particle or supramedial
particle are much better techniques to, uh, hold the shape over time.
So the, the toeses that you see or pseudotosis that you.
See sometimes with inferior particle will cause um more asymmetry in a unilateral
reconstruction case um so that's actually my particle of choice is superigio um you have
to think about the implant augmentation if you need to and augmentation mastopexy to the
contralateral breast or fat grafting, um, according to what you decide with the patients,
and you have to think about if you're going to do that simultaneously or delayed.
My preference is to do it at the same time, um.
You might not get the perfect results, but at least you put the framework in a situation that
if you have to come back to do a revision, it's a much easier procedure,
at least in my hands to achieve symmetry.
And if you're thinking about contralateral augmentation, the same,
same thing, you have to um choose an implant that has the projection that you're
expecting on the contralateral breast. In general,
if it's a contralateral augmentation that I'm planning, I will use a high profile or a more
high profile on the mastectomy side, and I'm gonna use a low profile on the contralateral
side so I can control for that projection a little bit better.
Um. I tend to use boost implants, their mentor for
um the mastectomy side just because it's more cohesive and they have less rippling with that.
Yeah. So, um, just to show you a few cases,
this is a lady who had a unilateral direct to implant with a smooth round,
not high, uh, 330 CC implants. She just had one surgery and uh it was an
anterior wrap with a P4HB um another patient, this lady.
Had a simple mastectomy through a limited incision um and you can get very good results
with fat grafting, and she had a contralateral augmentation mastopexy and got really good
symmetry that actually is kept over time and of course she had a nipple reconstruction.
Um, this is a patient who had a, um, a rarely sparing mastectomy on the right side and a
direct to implant reconstruction with AGM and a contralateral mastopexy augmentation in fat
grafting. I actually brought her back to surgery and I
added P4HB because, you know, uh, the AGM is stretches over time and and sometimes can give
you a suboptimal result.
Um, you can do that for patients who are actually difficult.
I find this is a body that can be very, very difficult to control.
Um, it was one operation, just a little bit of capsular contracture,
but it's still OK.
Um, patients who undergo um implant with a Goldilocks and why pat on the contralateral
side, um, you can get a very good result with one operation.
Um, again, this is the same lady that I showed on the first slide.
She had a very large implant. This is one case that I use an inferior pedicle
because she's very boxy and the superior pedicle will narrow the breast too much,
and I kind of want her to keep the shape.
I do use a very large dermabo flap to kind of cover that implant.
And of course there are situations that the nipple is low and you wanna do a nipple sparing
mastectomies and there are different ways to keep that nipple,
um, and, and uh do a lift at the same time, um, you know,
we just submit our paper for publication.
uh, in most of the cases that I do right now, what I use is a 3 pedicle um
supply. For the nipple areola complex, this is a dermal
particle. This was described by Georgia many years ago,
and, uh, it works really well. You see, this is a lady who had a unilateral
right mastectomy and a contralateral breast reduction, um,
and a second uh surgery for fat grafting, but you can keep the nipple alive,
um, that way. So, um, I think it's really important,
um, to understand that it's possible to achieve good results with a unilateral implant
reconstruction. I don't have 3D simulation, but Crysalis or eA
will allow you to control, um, for that, um, much better.
Um, I would recommend pre-pectoral reconstruction, um,
simultaneous contralateral procedures. I think it really helps.
And plan for revision with fat grafting, um, and we really need to use all the techniques
that we do for cosmetic surgery on our reconstructive patients and I,
you know, we heard so much about implant technologies so I'm hoping that in the future
we can actually create an implant that fits exactly that patient's breast and um and,
and that will come it's just a matter of time.
Thank you so much.
OK, our next speaker will be, uh, Nicola Rocco. He's right there and he's gonna be speaking
about salvaging implant reconstruction without reverting to autologous.
Thank you. Good morning, everyone.
Thank you again to the chairs of this uh excellent meeting for inviting me.
Thank you to the chairs of the session.
So I have no conflict of interest to disclose how to salvage implant
reconstruction without going to autologous tissues as we recently showed in a
Cochrane systematic review comparing implants versus autologous tissue that is going to be
published in the next few weeks.
Implant-based reconstruction remains the most prevalent form of breast reconstruction all
around the world, but we all know that implant-based reconstruction is associated to
some complications infection, implant exposure, capsular contracture,
malposition, and there are some risk factors associated to the with adverse outcomes.
We know about the adjuvant or new adjuvant treatments, radiotherapy,
chemotherapy. And uh usual risk factors as smoking status,
BMI, diabetes, and breast size.
But as we concluded in our review, around 9.6% of implant-based reconstruction will
result in implant removal, and we know that implant removal is not only a financial loss,
but it is also very frustrating for both surgeons and patients.
Roughly how to manage the exposed and infected breast reconstruction.
If we look at literature, roughly we have 3 options for the management of an infected and
exposed implants. That is explantation with or without a delayed
reconstruction, explantation and an immediate autologous reconstruction,
and implant salvages we will see in the next slides.
Anyway, um, the majority of patients, as we know with an infected or an exposed implants,
uh, will undergo explantation and will wait for the resolution of the inflammatory process
before further reconstruction, both implant based or autologous base is attempt.
And um the traditional pathway for managing implant failure is delayed autologous
reconstruction.
The rate of conversion in literature from implants to autologous is around 9.8%,
and as demonstrated by Scott Spier several years ago,
the conversion to an autologous reconstruction has been shown to improve the cosmetic results,
patient satisfaction, and quality of life.
Um, what about delayed implant-based reconstruction?
It is usually performed in two stages with or without the use of fat grafting that could help
in the reconstructive outcome.
And, uh, anyway, the device removal and the delayed insertion of the implant remains the
most conservative, the most safe strategy, and uh always Scott Spier found that after
explantation and delayed the reinsertion of a breast implant.
did not adversely affect the outcome of the reconstruction.
However, this is very important.
Most patients who undergo the psychological blow of an exploitation elect not to proceed to
a delayed reconstruction and will not have any kind of reconstruction.
So the chances of a patients proceeding to a delayed reconstruction are in the end,
similar to the likelihood of a successful implant salvage.
What is implant salvage? Implant salvage is the continued presence of a
prosthetic device after surgical interventions, and it is not the actual retention of the
original device. The goal is to maintain the results of the
original procedure.
Obviously the degree of the infection, the response of the infection to the initial anti
antibiotic therapy.
And the availability of adequate soft tissue coverage are all key factors to make decisions
and planning strategy in the management of these patients,
how to understand the severity, how to know how severe is the infection?
Well, we should look at local signs, systemic symptoms, and obviously blood tests looking at
inflammatory um laboratory tests and white blood cell counts.
Anyway, all we can call aggressive measure to try implant salvage require a
willingness to attempt this salvage on the part of both the patient and the sergeant.
This is it's very important to clearly communicate to the patients the risks of of
trying to salvage an implant and all the alternatives.
So shared decision making is primary in this kind of in treating this kind of patients and
it's primary to understand patient values and preferences.
There are some cognitive exercises that could help patients eliciting their.
Uh, their values and their preferences you can see on the left side of the of the screen,
uh, you can ask to your patients how important for that specific patients is to have minimal
scars on other parts of the body, how important is to have the lowest risk for very serious
complications? How important is the hospital stay for that
specific patients. I always suggest to use this 3 talk model for
your shared decision making with your uh just shaking decision making process with your uh
patients that is made of 3 times 3 talks. The team talk in order to create an alliance
with your patient. The option talk in which you present all the
possible advantages and pitfalls of that specific technique,
then going to the final decision, the decision talk, understanding the values and the
preferences of the specific patients you you are going to treat.
If we look at the experience in the algorithm proposed by the group some years ago by the
group of the Marie Curie, there are generally, depending on the degree of
the infection, the size and the position of the mastectomy flap defect,
there are some types of implant salvage.
That is the possible primary suture after the exchange of the implant for one of the same
size of the original primary suture after exchange of an implant for for a smaller
implant or an expander, a thora abdominal tissue advancement and the exchange of the
implant for one of the same size and the use of latissimus dorsi flap with an implant of the
same size or and I think that Cicero will talk about this also later on.
So successful salvage of per implant infections was described since 1965,
and the advantages of implant salvage over some more conservative management include a better
aesthetic result with the preservation of the skin sparing mastectomy skin envelope,
so avoiding the need for larger flaps with more extensive donorcy morbidity.
And uh also you avoid the risk of reinsertion, re-expansions, and you
can also reduce the uh the the possible delays of
the adjuvant therapist, and this is very important from an oncological point of view and
also Scott Speer demonstrated that immediate salvage, even if unsuccessful,
may not adversely affect future reconstruction should the initial attempts fail.
I just would like to show you our experience with what we can call an extreme measure in
patients that are really motivated not to lose their reconstruction,
not going flat, and they really motivated not to go for an autologous reconstruction.
We use negative pressure bone therapy a state we proposed we published some years ago.
Our experience with this technique proposing a staged treatment of implant exposure using
negative pressure boom therapy, allowing a rapid repositioning of the implant after
complete clearance of bacteria from the implant pocket.
This is one of the patients we treated, the 50 year old BRCA1 mutated patients who underwent a
left neck sparing risk reducing mastectomy. She already underwent a right mastectomy for a
triple negative breast cancer some years ago.
With a dual plane approach and with the use of an ADM.
Well, after some days she experienced this very uh bad complication hematoma skin necrosis on
the lower side of the wound.
Uh, we performed the US guided drainage of the seroma hematoma,
and it was positive for Staphylococc Staphylococcus ominous.
And she underwent targeted antibiotic therapy with daptomycin.
We also performed surgical debridement of the skin necrosis,
and we had implant exposure and ADM exposure. So what we did,
we removed the ADM and the implant. We accurately rinsed the residual cavity with
poviudine, be poly. It after performing some microbiological swabs
on wood margins inside the cavity and at the same time we inserted some negative pressure
dressing sponges in the residual cavity, filling it to excess in order to not lose the
skin envelope and not create, not have a skin envelope retraction.
We sealed the cavity with 125 millimetres of mercury in negative pressure therapy.
Aiming to remove the residual fluid, reducing edoema and sterilising the cavity.
Well, after 44 48 hours we took again the patient in the operating room.
We did another washout.
We performed new microbiological swabs and we replaced the.
Sponge and negative pressure boom therapy we repeated this process for every 3 days until
cultures turn negative for any micro microbiological growth with 4 excesses to the
OR in 3 weeks.
And when we obtain a negative result for bacterial growth in the residual cavity.
The patient was ready for the final procedure that was the insertion of a new implant in the
same surgical pocket and final closure of the wound in 3 weeks.
Well, this is not the best cosmetic reason, the best aesthetic and reconstructive result,
but we fulfilled the patient's expectation and fulfilled the patient's preferences without
the negative psychological impact of delayed reconstruction.
There is also the experience of our colleague Fareed Maibodi from Australia that also who
also used negative pressure boom therapy in a case series of um published in
2021 experiencing, experiencing 83% of implant breast reconstruction.
With severe infections, successfully salvaged using negative pressure wound therapy without
recurrent infection during follow up and with the mean length of hospital stays of 11 days.
Obviously patients should be really motivated in going several times to the OR and in
performing this kind of reconstruction. So summarising.
Patients with an infected or an exposed implant traditionally undergo explantation and delayed
reconstruction with autologous flaps or also implant repositioning.
Also immediate autologous tissue based reconstruction is an option,
but there there is growing awareness that a periprosthetic infection or exposure does not
necessarily condemn an implant to removal.
So we can go for implant salvage defined as the continued preferences,
a presence of a prosthetic device after surgical intervention,
not the actual retention of the original device with the aim of preserving the results of the
original procedure. But this is primary a shared decision making
process with a proper assessment of patient values and preferences is mandatory for
choosing the best management for implant infection together with your patient.
So this is Naples, but do not forget also Milan for next December for the NBN aesthetic
brass meeting from the 12th to the 14th of December.
Thank you. And Get my
daughter. So our next speaker is Roy Devita,
and he will talk about conversion from prefectural to submuscular plane,
when, why and how.
Thank you so much.
When we are obliged to go from retro pack to to pre-pack, uh,
first of all, my disclosure, I'm temporary consultant for,
uh, Becton Dickinson Xaha Lab Bank, mentor, and Polytech, and The two
possibility, PrePAC versus retro pack, and you know that.
This may My commandment actually, if you try to prepare you never go back.
It's, it's the reality then it's so nice and so beautiful, the result is so.
Dressful to go back and to change the plane and go on back,
but sometimes we are obliged.
Especially because this is a break pack, the bilateral breast reconstruction,
the patient had a, uh, um breast augmentation previously, and she came with a
breast cancer on the right hand side and um was a BRCA positive and then she did
a uh undergo to um.
Bilateral mastectomy and breast nipple sparing mastectomy breast section 2.5 year post op and
you can see laterally the and and and profile the results is better on post op than pre pre
uh pre-op and it's something really unbelievable.
10 years ago we cannot think about it, uh, because the,
the results after the reconstruction was always not so perfect as thou.
Well, In, uh, actually, I can tell you some general
advice when we have to move from uh pre-pack to retro pack.
If you have good tissue quality, no atrophy, good elasticity,
more than 1 centimetre, the edge is less than 50, and we have no overlap on the breast,
you can go pre pack.
On the other side, if you have bad tissue quality, less than 1 centimetre,
more than 50 years of age, and hepatotic breast, I think it's much better going straight to
retrofat. Then why and when you need to move when the
defects are so important and the outcome is so poor, then definitely you have to to live the
way. The most common conditions are implants is too
visible, the skin envelope is too large, and you have huge wrinkling.
And You can have like in this case, implants too visible.
You can have a skin envelope too large.
You can have you drinkling.
And actually this condition can be blended each other, and you're gonna have
type 1 and 3 together.
Like in this case, or you can have type 2 and 3 together.
Like in this case, Then for sure.
You can do a lot of things to move from prepack to retro pack
and you can remove, you can reduce the envelope and then you move from a nipple sparing to an
inverted scars, reducing the skin envelope and having good results.
Or you can do nothing at all. You just create a sub muscular pocket and
you change the plane without doing any other scars or any other surgical procedure using the
same approach that she had in a previous surgery um and just hiding the
implant in a better way.
Then another case in which I did, I didn't do anything at all,
just I changed the implant, I changed the plane, I go from rape to prepack after any postpar
mastectomy. Nothing, nothing more to say and it's the.
This is a very awful results actually uh you can see the implant is so visible,
the, the wrinkle is so huge, uh, and if you go without removing any
millimetres of of tissue of, uh, skin, you can have very good results
going from very back to retro back you would say.
Uh, the patient was really disappointed about the results.
In this case, I did something strange, you know that in pre the patient arrived to me uh with
this kind of condition, but she had radiation.
Then I, I thought that probably in, in next month.
Uh, the results will be quite good as well without reducing the skin envelope and I
did anything. I just changed the plane and after,
uh, one year I had a very good results is 2 years post-op,
and but I didn't anything. I just changed the plane was just a shrinking
related to the radio, uh, therapy treatment that she had in uh in post-op after the
previous surgery. That's the results on on later review then the.
In this case, for sure, the pocket was too large, uh,
huge, uh, the, the, the breast was patotic but for sure was already in a
pre-op when she arrived when was planning the surgery, the results,
the, the, the, the breast was probably a little bit better,
but anyway, where it was patotic, it was already patotic for sure.
Then I did just I reduced the, the, the skin envelope and I moved from retropec to pre-pack.
I reduced the pocket and I changed the implant.
On later view and on profile, then what I want to say that it's very important because
in some way I'm responsible for a lot of these cases because I organised many,
many courses, surgical courses, and I explained the pre-PAC.
I I do courses for pre-pack positioning and probably many,
many surgeons come and see beautiful results, but they don't consider it how you choose the
patient then the best technique performed perfectly can lead any way to a
very poor results.
Because it is always a matter of indications, always then choose the right patient to
do the right surgery. If we can, we go pre-pack because I think there
is nothing comparable with the pre-pack results.
It's so natural. The patient is so happy, the breast is soft.
Everything is wonderful, but sometimes we are obliged to go retro pack.
Never forget.
Thank you.
Our next, our next speaker will be Ash Kathari, who's going to be speaking on mesh and implant
reconstruction again, what, why and how.
So good morning everyone and thanks to Marlene Ja Jamei,
uh, and of course Maurice and Eric for the kind invite to be part of the 10th anniversary.
So it's an honour to be speaking on the 10th anniversary, and thank you very much.
My disclosures again will not interfere with anything I say.
But today my talk is on, it's not evidence-based because there is a paucity of
high level data. So I'm gonna tell you a story,
and that story is when can we use.
A mesh and when should we avoid using a mesh? And then when we use it,
how should we use it?
So we look at lessons learned from history, and we look at surgical evolution,
we look at surgical innovation by Technological advances and surgeons and mavericks,
and then we'll look at data as well.
And then I'll leave you guys to make up your own mind on what's the best way forward,
but remember one thing in surgery, always is always never the right answer.
The circle of life is important. History.
We started off with subcutaneous mastectomies and implants,
saline implants in the subcutaneous spleen, high complication rates,
so we sought refuge under the muscle because we thought, OK,
if the implant is not exposed, we can save the implant under the reconstruction.
And then because of advances we got the biological meshes,
we got synthetic meshes, and then we went to dual plane to get better aesthetics and then
implant companies of course tweaked that we can charge them more by making bigger meshes,
so they made bigger measures and then we went pre-pek.
But what changed? What changed between 1960s and 2010?
What changed was, I think breast surgeons and plastic surgeons became more aware of
anatomical planes. The mastectomy flat thickness has changed.
We were doing proper mastectomies, and that was allowing people to put implants in the pre-pe
plane. And then you had innovators like Roy,
who said, OK, we've got good mastectomy planes.
Why do I need a mesh? If I can get a stable implant and put it in the
prepectoral pocket. This is early data that presented by Roy.
Then there was again concern about, well, does polyurethane cause ALCL?
And if you look at the the cases around the world.
They were reported by a single company, let's not name the company.
But the polytech implants hardly had any ALCL, and this is worldwide data.
Of course, Australia is an outlier because everything happens in Australia.
And then you have an overview.
And then we come to another friend of mine, Cicero, who was here in the first row,
but his was more a creation of necessity.
He Identify that prepec is the plane you need to be in.
But they didn't have ADMs there, so he created his own technique and started doing these
implants pre-E, and he's published his data and it's there for everyone to see,
so there's no point me going through it, but he's got very good results and very acceptable
results, although there's a slightly higher explantation rate,
but that was probably part of the early learning curve and now his explantation rate,
he shows me is about 2 to 3%, which is great and as good as anyone else.
So why then are we using meshes?
I said there is no data, so let's talk about why we are using meshes.
Now, a whole reconstruction is about anatomy. If you look at it,
there is a content and there's a container.
The container is the skin that we leave behind.
Or the case, the pillow case, as I call it.
And then you have the content of the pillow, and you tell a patient your pillows lumpy.
I'm taking that out and I can put a new pillow back in.
If it's an autologous tissue, you can tailor, like Andrea said,
you can tailor the tissue to match the box so you can get a nicer,
better aesthetic result with implants, you don't have that liberty.
With implants, if your implant is malpositioned, your skin is not going to shrink on the table.
It takes time to shrink or you can do manipulation of the skin of the skin envelope
and try and bring that so that the nipple sits exactly where you want it to sit,
which is slightly above the midpoint or the highest projection point,
so you get a nice outward and upward looking nipple.
But that can happen if your implant falls too low.
So you don't have that luxury.
And when you want a luxury to create a nice bespoke breast,
you want to create, you want to control the IMF, you want to control the takeoff point,
you want to give her the cleavage.
You need very, very good pocket control and then.
This is what surgeons became. We became control freaks.
We want to control that pocket.
And this gave us these results. We have lasting results,
so these patients have all had their surgery more than 3 years ago in follow-up,
so we were able to give them these contours and maintain them over a period of time.
Unilateral mastectomy, are preserving mastectomy, again,
3 years down the line.
With meshes, and these are again patients with larger breasts with implants 3 years down the
line. And for people who don't believe that if you
fix the implant, you lose, the implant is just there, it's like a rock on the chest wall
because of the mesh. It's not, because I hope the video plays.
Because that's what happens with implants and meshes.
You have nice mobility of the breast.
And coming back to Cicero, who's very quiet in the front row,
he also has a trick up his hand, up his sleeve, which he doesn't tell us.
So he uses his magic stitch stitch of his which he takes from the lateral part of the lad dorci
and crosses the implant and then anchors it here.
So he's also controlling the implant in the pocket, but he's doing it in his own way.
It's not a mesh, but it's his own device.
And then you've got the C word which is capsular contracture.
So what does implant, what does the ADM do in terms of capsular contracture?
We know how how bad capsu contractors are and how bad they can get.
But what this study showed us and it's very It's a very nice study innovatively done and
basically based on histology, so you can't say it's rubbish basically.
They did two stage reconstruction in 30 patients, so dual plane reconstruction in 30
patients. 15 had radiotherapy, 15 did not have
radiotherapy. They went back to swap the expander for an
implant, and what they saw was amazing.
In patients that did not have radiation therapy, when you look at the implant,
and look at the capsule under the muscle versus the capsule under the skin or the dual plane
under the ADM, there's a 6% thicker capsule under the muscle.
And when it's radiated, that goes up to 13 times thicker.
If you look on balance, it doesn't change, but the capsule thickness does change.
And that is what they put it down to that you know decrease macrophages,
decrease inflammatory response, and that's why you have lesser capsular contracture.
And then this is borne out by a bigger review for those of you who are data driven.
There's a systematic review that says the very same thing that ADMs bring down capsular
contracture. So there's another indication for use of ADMs.
And then remember one thing and um Charles Rehnquist.
Alluded to this really well in his talk yesterday where he said that if you mess with
the Cooper's ligaments, And you put an implant in an augmentation in a breast,
smooth implant, nanotexture implant, it drops.
Now think of a mastectomy, where it's got no corpus ligaments.
So you've got skin which is floppy.
And then you're putting an implant in there and you want that implant to maintain that shape.
If it's not supported by anything, that implant is going to drop because that's what it does.
Gravity, Newton's law.
No one's exempt from it.
And when that implant drops, it stretches the bottom bottom part of the skin and like
bottoming out, you can see these kinds of results on implant-based reconstructions unless
you try and stabilise that by cheating and using an implant which is sticky,
which is the polytech implants, which I think was what Cicero started off with,
but now he's moved to smooth and Roy's data was all about polytech implants.
We know plants will stick like glue and velcro.
We know they don't form capsules.
Baste form capsules, when the polyurethane sheet is absorbed completely,
the capsular contraactual rate of a polyurethane implant is exactly the same as any
other implant, but that is 8 years down the line, so you don't see any adverse effects of
polytech implants 8 years down the line.
But we are now talking about ALCL and nano textured and micro textured and no texture and
smooth implants and round anatomical and smooth anatomical.
All these Behave like smooth implants, so the implants that we are now using to bring down
the rates of ALCL, which is a smooth and a nano textured, behave exactly like.
Smooth implants and they'll drop.
The other problem is when you've got a large pocket.
Now a lot of you here are plastic surgeons, and a handful of breast surgeons.
So you guys will come into the theatre room when we have ruined the whole flap for you.
That's what you guys say.
So let's face it. We created a big pocket,
we've transgressed every boundary, including the IMF,
and then you guys have come back, you have to come in,
put an implant in that pocket and try and make it look good.
So either you go two stage, or then you use an ADM and then tailor the pocket.
Patients have different skin textures. They have lots of elasticity.
They have different skin thickness. Again, you could either go two stage in this,
or you could use an ADM in a dual plane.
Large breasts.
Even in the absence of Bli in the NHS, you don't get them.
You can do it in the private sector, but you don't get them in the NHS.
Big implants like this, you are going to get bottoming out,
revision surgeries.
is when you use implants and when you use meshes.
So let's look at the data.
All these studies, the last two being fairly large numbers,
show that there is a better aesthetic outcome with the use of ADMs,
OK? So we know that acidic outcomes can be improved
by the use of ADMs.
This is not a large study.
9,502 women.
And the two main things are capsular contracture.
In primary and division is low.
Long term results for asymmetry and implant malposition is better with meshes.
So this is what you hear people saying, the extra layer covers the implant.
I don't believe the first two.
What I do believe is if properly done.
It gives you better control for the implant location, bespoke breasts,
reduces the risk of capsular contracture, especially with radiation therapy,
and also for better aesthetics and patient satisfaction.
So now, when will you not use meshes?
When you're using expanders, please don't use meshes.
There's no point. You get, you get tab expanders today.
So the expander is going to stay where you put it.
Data, here it is.
Doesn't help when you've got expanders.
When you've got nice small and moderate sized breasts and you want to do a direct implant
pre-pectoral, using a microtexture or or a nanotexture implant,
you can do it. You can do it provided you've got a nice
envelope and there's a snug hand in glove.
The implant goes and just wants to sit there, doesn't want to go anywhere else.
And as a surgeon, we've seen this, that you put the implant and it just sits there,
sits beautifully. So in these patients, yes, in patients that
have good skin elasticity, younger patients, they don't have the droopy,
you know, totally smokers who have absolutely no connective tissue.
These are the patients we have a problem with.
So let's look at the good, the bad and the ugly of of meshes.
The good is all the things that we've already said.
The bad is complications and costs.
You can't deny that they're expensive, and you can't deny that they have more complications
with meshes. And then how do we do it?
I think Roy has already said this, so we skip over this.
Has the goose been cooked?
No, it isn't. The jury is still out.
For those of you who are waiting for data, these two trials will report,
and when they report, you can choose what to do. But in the meantime,
there's something called common sense.
Tell that man standing up that if he jumps, he's not going to die.
That is science, and sometimes common sense and science needs to overtake randomised controlled
data and pre-pector reconstruction whenever possible and safe is a better option.
So the take home is patient selection and shared decision making is the key,
as even Nicola said, shared decision making every time,
all the time, managing expectations and what the patient wants a thin patient pre-pectoral,
she's going to get rippling, she needs fat grafting.
Tell her that before the operation and you'll have a happy patient.
In every reconstruction, no matter what you do, the flap,
the flap, and the flap is the most important part of your reconstruction,
whether that's autologous, whether it's implant based.
You do a mastectomy properly, that's gold. Everything else is a spark around it.
And then do what works for you.
Get your own technique, stick to it, and please make sure that one size doesn't fit all,
you need to find your own niche and make a name for yourself.
Thank you very much for your time.
So thank you. Now we come to our last speaker,
Cicero Orban, and he will talk about implant reconstruction failure,
aesthetic um strategies for removal, alternative reconstruction,
and the role of the LD.
Good morning everybody. I'd like to thank the organisers for inviting
me to this wonderful meeting for the first time.
And I am uh the bad guy.
I came through to from Brazil to show you the bad results completely different from yesterday
when you saw such a wonderful results we discussed about the perfect breast
today I'm gonna show you the possible breast in the settling of cancer treatment.
So implant failure.
I don't have conflict of interest to disclose right here.
Some of these complications are not mine, but all could be mine,
and some of these cases could have more than one alternative to solve.
And as the bad guy, I have some bad news.
We have. The current knowledge on how to manage implant
failure is based on expert opinions, cases series, low level of evidence,
and there is no standard technique.
There are many contradictions between us as experts on how to manage
difficult cases, how to manage complications.
So beware, some data here are not evidence based medicine.
The aim of my presentation here is to try.
To show you a logical way to organise your decision making process when you have this kind
of problem in 4 practical golden secrets.
Don't tell To anyone outside here first secret breast implants,
yes, it's true, have complications and unfortunately this is not uncommon in breast
reconstruction. Well, this is not the New England Journal of
Medicine. This is New York Times.
5% of failure in reconstruction and 1 in 5 requires more than one surgery.
And we have 4 causes of implant vain.
First, specific related to implants. This is not the most frequent one.
Second, yes, as Ash showed you and you specifically related to mastectomy
technique. I use it to say to to tell to my colleagues
maybe it's necessary to retrain our mastectomy flaps, to retrain our mastectomy
technique. I'm a breast surgeon.
I'm sorry. Specifically related to radiotherapy,
specifically related to emotional problems, which is the most difficult one of life.
I have some interesting data from here.
When we switch it from super PAC to pre-pack, we had a slight better result but not
statistically significant.
We lost between 10 to 12% in the past, and then we, we,
we went to 9.2% of implant failures in our process direct to implant after
mastectomy, but we had.
A pleasant surprise when we switch from smooth from texturized implant to smooth
ones. Why we had this difference?
because I'm a better surgeon because I'm going, I'm doing better.
my mastectomy flaps, no, because of the seroma that we have together with texturizing
implants. We don't have this kind of seroma in smooth
implants and in poliota implants.
This is the best result I had in 20 years of breast reconstruction.
Seroma, together with necrosis, they are the worst enemies in implant reconstruction direct
to implant implant reconstruction.
Relates to mastectomy technique. OK, we can have flat necrosis,
we can have infections, we can have wound diseases, and we can lose the implants,
big disasters.
Big disasters. You're a resident.
This is from my resident, not me.
Uh, when you have this kind of dehesence, it's necessary to try to do something,
but together with seroma, ah yeah, yeah, yeah, yeah, yeah.
I try to put some stitches, of course, and you put some stitches.
I removed the most fragile part and we close and we pray.
But nobody listened to us upstairs.
And when you have the 2nd, the 2nd exposure, so it's necessary to remove.
No way. This is the same page, no way.
And this is the result after.
Very nice. Again Radio therapy radiotherapy matters
and how it matters.
They are radiotherapists are our friends and our enemies at the same time.
When you don't have radiotherapy, it is a medium disaster.
She is a mutated patient. We we did a bilateral mastectomy,
pre-pack re implant. She lost her right implant.
So just put an expander three months after and you have a good result.
Just do the symmetry on the other side if we remove some skin.
Excellent. But OK, good result like yesterday.
But when you have radiotherapy, many times it's necessary to add a flap,
for example. This is a big disasteradiotherapy,
explantation, nipple sparing mastectomy, difficult patient,
LD flap, temporary expander expansion, change the expander for the implant and
uh contralateral symmetry, not perfect, not like like yesterday,
but it is the way we can do a possible breast, not the perfect breast as
we saw. Yesterday, and this is the possible,
the final outcome. Another case, she had an implant exposition on
5 years after radiotherapy.
No infection, just this thing skin.
So LD flat we solve the problem, very good, excellent.
Not perfect, but better than she had before and better without uh uh removing
the implant. Second secret remember yesterday with Charlie,
I don't know if he's here, but he put 3 S's, uh, simple, stable,
and safer.
I had two Ss.
Keep it simple, stupid, so lower surgeon expectation.
Go to the most simple before go to the more complex surgery.
Don't go to the flat first, go to lipo filling first because then when you go to lipofi first
like this disaster, we can put some lipo filling inside and we can do a miracle.
I don't do miracles but we try uh we can expand.
This skin after lipo filling. So, put lipofilin,
put an expander 3 months after, and you can expand this skin.
This is for your, uh, after result.
This is the same case.
Bilateral mastectomy, uh, locally advanced on the left,
left side, and this is after lipofilling expander, expansion and,
uh, change for the definitive implant.
This is something that we can do with this hybrid reconstruction.
Third secret, most relevant failures are not technicals.
They came from this judgement.
When we we when we have this balance between possible outcome and patient's
expectations. Well, most significant question is how to
decide. Uh, well, The secret of happiness in breast
reconstruction. Our secret here. Don't.
Under promise and over deliver.
Oncoplastics reconstruction, this is not a static surgery.
The logical way to decide finally I'm, I'm arriving at the,
at the end is when you have a failure.
We have 3 points radiotherapy.
Infection Or necrosis or everything together which is a big,
big, big disaster when you have radiotherapy. So you have to,
the first is to do a lipofiing and try to do a temporary expander which in the past was bad
was uh uh bad medicine new exposure. So then you go to myocuano lab.
When you have infection together, a disaster, but no infection,
no radiotherapy. Suture.
You will, you will save between 60 and 50 and 60% of your cases with no
infection. New exposure, well, implant removal,
and then you do temporary expander 3 months after and direct implant 2 to 3 months after
expander. When you have necrosis.
Well, implant name removal temporary expander and the same way.
Extensive necrosis, implant removal.
No big man, no, not big necrosis, just a few, just a small necrosis,
no infection, and we can't try to do the suture, but if you have a second exposition now
and then it's necessary to do uh uh a removal, implant removal.
Well, in conclusion, this is the most unpleasant part of our game.
Of course, but it should be included in our skills pocket.
Time and experience to reduce our risks and better our competences and prevent and solve
them, of course, and oncoplastics, recontive surgery is not
aesthetic surgery.
This should be clear to our patients since the beginning.
Thank you so much for your attention and thank you again for the invitation.
OK, I think we've uh heard some really interesting talks and some common themes and
some challenging cases, so I wanted to open it up for questions and answers.
But I wanted to kind of start, let me, I'll get there but I wanted to kind of start it off with
just one of the things we've heard about is this shared decision making process,
and I just kinda wanna see what people's perception is of what shared decision making
actually is. So personally I think shared decision making is
really getting patients to agree with what I am recommending and you may.
And that that is because most patients aren't really in a position to tell you what they want
and what they want you to do. They don't understand the nuances,
so I, I have patients all the time, you know, with a D cup breast who say I want a nipple
sparing mastectomy and direct implant reconstruction and I want a de cup.
That's not really possible.
So I think this shared decision making is you have to base.
Let patients know what is possible and have them agree with it.
I just, you know, because some of the talks on shared decision making.
Tell me what you think. So Nicola, I mean,
shared decision making, you mentioned it several times.
Yes, no shared decision making is, uh, uh, there are several theories between,
uh, behind shared decision making.
And it's obviously not easy.
A good surgeon probably not could also not have proper skills in
transferring information to patients, but it's also very important.
I showed you the three talk model in which you have the team talk,
the option talk and the decision talk.
In the option talk, your communication with the patient should be very balanced.
You should be not. biassed by your, but I know that it's very,
very difficult to not be biassed by your convictions.
So you should pose at the same level all the options with their evidence from the literature.
I know also that share decision making also depends with the patients you have in front of
you. There are patients who would like who would
prefer a paternalistic approach in which you decide for her or him.
And others like to be to be independent in their choice,
so it's absolutely, absolutely not, not easy, but I think that we should aim to have a
proper shared decision making because uh our choice will be the best choice if it is shared
with the patient. I'm a lot less democratic.
I think the patient has no knowledge and no possibility to can share the.
They have, they, I think that they have to understand, uh,
which are the possibility. We are like magician.
01:00:00.030 --> 01:00:04.629 Uh, we can choose the, we, we, we, we, we let the patient choose the cars that we want.
01:00:05.360 --> 01:00:12.010 And I think that the um you need to have all the pos all the options in your
01:00:12.010 --> 01:00:18.239 hands then you can do autologous uh prepackretoack as move text to everything
01:00:18.860 --> 01:00:20.100 and then you can offer.
01:00:21.080 --> 01:00:25.050 The best that you think is good for the patient.
01:00:25.669 --> 01:00:32.169 And the patient must understood that you are working for her uh in the most honest way,
01:00:32.419 --> 01:00:34.570 but I don't think that we can share the process.
01:00:34.860 --> 01:00:41.300 But I, I, I, I like this, this question because this is an ethical question and it is,
01:00:41.310 --> 01:00:44.159 uh, we have, um, different cultures.
01:00:44.500 --> 01:00:48.780 For example, in American, uh, people, American patients, uh,
01:00:48.939 --> 01:00:53.340 Italian patients, British patient, Brazilian patients, most of Brazilian patients.
01:00:53.929 --> 01:01:00.040 Although they they wanted perfect results, it's very frequent our practises they ask it to us,
01:01:00.290 --> 01:01:02.010 Doctor, what would you do in my place?
01:01:02.770 --> 01:01:09.280 And as doctors, as, uh, surgeons who are dealing with difficult situations like breast
01:01:09.280 --> 01:01:15.790 reconstruction, it is our, our, our, our, it's very important
01:01:16.159 --> 01:01:20.479 to show the patients the good options.
01:01:21.239 --> 01:01:27.000 Don't put the options that are not patients that sometimes arrive to you to asking to do
01:01:27.000 --> 01:01:30.060 something. Impossible.
01:01:30.489 --> 01:01:37.389 It's not your, uh, you are not in position to do something that is impossible because at
01:01:37.389 --> 01:01:39.100 the end you have a bad result.
01:01:39.959 --> 01:01:45.949 And sometimes a claim and you have no defence in this in this situation so
01:01:46.479 --> 01:01:52.040 uh I think that we should put the good options for the patients and the patient has the the
01:01:52.080 --> 01:01:55.679 the the right to go to one or other option.
01:01:57.169 --> 01:02:01.780 The US, yeah, we right now we see patients who come for 5 opinions.
01:02:01.800 --> 01:02:05.939 I have patients come from all over and they've seen several surgeons.
01:02:06.300 --> 01:02:10.860 Um, I think it's really important to expose the patient what can be done and what cannot be
01:02:10.860 --> 01:02:13.969 done, but I think when we talk about shared decision making,
01:02:14.530 --> 01:02:20.050 I don't do my mastectomies, so I think it's really important to decide this as a team is
01:02:20.050 --> 01:02:24.100 you, your patient, and the best surgeon that's gonna do the case with you because sometimes
01:02:24.100 --> 01:02:25.770 you think something is possible.
01:02:26.290 --> 01:02:29.000 But then you're gonna hear from the breast surgeon, you can't really do that.
01:02:29.699 --> 01:02:33.739 So, um, so I think it, it needs to be a combined approach.
01:02:33.830 --> 01:02:39.060 I tell the patients everything that I think it's possible to do and let them go home.
01:02:39.850 --> 01:02:45.610 And read all the information by the way, there's plenty of research that shows that
01:02:45.610 --> 01:02:49.610 patients understand it to a 6th grade level so anything above that,
01:02:49.649 --> 01:02:50.760 they will not get it.
01:02:51.090 --> 01:02:54.370 So in plastic surgery, unfortunately most of what is available,
01:02:54.409 --> 01:02:56.760 it's above that, it's 8th grade I guess.
01:02:57.090 --> 01:03:02.919 So I think it's really important to now um describe the information in a very simple way,
01:03:03.290 --> 01:03:06.979 um. I do give my recommendations like you do,
01:03:07.310 --> 01:03:11.780 but I let them go home and think about it and come back with uh with what they decide.
01:03:12.189 --> 01:03:16.459 Yeah, because I mean retention is only about 30%, you know,
01:03:16.590 --> 01:03:22.030 we give them so much information they just can't retain it at all of course it's also
01:03:22.030 --> 01:03:27.899 important to to have a second consultation with the patient to live some time as Andrea told
01:03:27.899 --> 01:03:30.709 and also if I can add something.
01:03:31.010 --> 01:03:36.780 It's also important that you can you can have a proper shared decision making when there is a
01:03:36.780 --> 01:03:41.879 grey area in which there is no clear evidence, high level of evidence towards one direction,
01:03:42.040 --> 01:03:45.429 one choice or the other. In this way, I agree with Roy.
01:03:45.689 --> 01:03:49.290 I will tell the patient that one is the best option to do,
01:03:49.320 --> 01:03:55.320 but if we have no high good good level evidence, the choice should be shared.
01:03:56.070 --> 01:03:58.300 Yeah. And if I can mention one thing, I think there
01:03:58.300 --> 01:04:02.419 is a lot of opportunity for us as plastic surgeons to educate those patients through
01:04:02.419 --> 01:04:07.659 social media um there's actually a study that shows that most of the information in social
01:04:07.659 --> 01:04:13.010 media about breast reconstruction is is patients, uh,
01:04:13.100 --> 01:04:14.300 it's created by patients.
01:04:14.709 --> 01:04:17.419 They try to answer their own questions. There's very little.
01:04:17.500 --> 01:04:20.729 There's actually physician trying to educate the patients through those,
01:04:21.060 --> 01:04:23.570 um, different procedures. We think there is a lot,
01:04:23.780 --> 01:04:30.020 but actually there isn't so they are discussing their cases and their complications and their
01:04:30.020 --> 01:04:37.020 outcomes and when they come to you sometimes the ideas that they have is so not possible
01:04:37.020 --> 01:04:40.929 it's so unrealistic that's difficult to kind of bring them back to track.
01:04:41.399 --> 01:04:45.989 Very important to educate patients, but it's important to to educate the doctors there.
01:04:47.189 --> 01:04:52.330 You do not create more problems than we already have, and it is difficult to say no.
01:04:53.370 --> 01:04:58.090 Independ of country you are very difficult it's easy to say yes.
01:04:59.199 --> 01:05:02.679 Sometimes we have to let patients go though. I mean we have to be in a position where if
01:05:02.679 --> 01:05:06.360 they don't necessarily or if we don't agree on a plan,
01:05:06.399 --> 01:05:09.830 it's like here are 3 surgeons that you can see to get another opinion.
01:05:10.010 --> 01:05:13.679 I think it's important to kind of give them that option and document,
01:05:13.879 --> 01:05:16.469 at least in the United States, that we gave them that option.
01:05:16.479 --> 01:05:21.320 So because we always have to think about the liability and the legality of this let's open
01:05:21.320 --> 01:05:23.919 it up for uh audience questions. I know there were some.
01:05:27.129 --> 01:05:30.399 Thank you very much. um, just wanted to ask a question about
01:05:30.399 --> 01:05:34.540 changing the plane from a prepec to a sub pec for, uh,
01:05:34.850 --> 01:05:38.110 uh, reconstruction cases. So what if, for example,
01:05:38.159 --> 01:05:42.159 you go in, you're planning to change the plane, and we've we've heard a couple of times
01:05:42.159 --> 01:05:44.469 yesterday and today about the peck being like very small,
01:05:44.520 --> 01:05:47.120 thin, and not really being able to go down that route.
01:05:47.199 --> 01:05:53.610 Is this as the sort of case where you will use an ADM or would you adjust the pocket?
01:05:53.770 --> 01:05:55.110 What what would be your approach?
01:05:56.100 --> 01:06:01.280 Actually 10 minutes is, is not enough to explain all the options and I try to make an
01:06:01.280 --> 01:06:06.570 overview of whatever view if it it depends case by case because,
01:06:06.939 --> 01:06:13.899 uh, I, I, I propose just some of the, the most common situation but time by time you have
01:06:13.899 --> 01:06:17.260 to make small adjustments sometimes use mesh sometimes.
01:06:17.699 --> 01:06:24.649 I prefer to use ATM, but uh um you, you could use any way it's I,
01:06:24.820 --> 01:06:31.739 I think that's the most that you are familiar with um you are sure that you don't
01:06:31.739 --> 01:06:37.870 have any, any other problems because the first thing is that they come to you for a secondary
01:06:37.870 --> 01:06:42.620 surgery uh, she was unsatisfied she is unsatisfied.
01:06:43.139 --> 01:06:47.790 Uh, and then she want to fix the problem and you have to fix it.
01:06:48.429 --> 01:06:55.169 Then, uh, it, it, according to your, uh, skill to your experience,
01:06:55.500 --> 01:07:00.469 you will choose the best in this moment that can be using something else.
01:07:01.560 --> 01:07:03.020 Mhm. Thank you.
01:07:03.169 --> 01:07:08.129 No, Roy, I noticed in a lot, a lot of the conversions from pre-pack to dual plane in your
01:07:08.129 --> 01:07:12.379 case where. Larger breasted nipple sparing, a lot of
01:07:12.379 --> 01:07:16.540 rippling and wrinkling so you know sometimes it's just like I,
01:07:16.620 --> 01:07:20.860 I'll have to tell patients, well, nipple sparing is probably not gonna be a good option
01:07:20.860 --> 01:07:24.659 if you wanna go prepectoral just because of these skin issues,
01:07:24.860 --> 01:07:29.340 especially if it's a thin mastectomy slab. So how do you have that discussion about
01:07:29.620 --> 01:07:33.489 whether to save the nipple or remove the nipple in a large breasted patient?
01:07:33.780 --> 01:07:37.209 I must say that I am a lucky boy because I do mastectomy on my own.
01:07:37.899 --> 01:07:42.179 Then it's completely different, so we can only completely different you can't blame anybody
01:07:42.179 --> 01:07:48.179 else then yes exactly and then if if you do if you perform on your own,
01:07:48.260 --> 01:07:54.780 you know perfectly if you can have some problems otherwise I can suggest to use um ICG.
01:07:55.580 --> 01:08:02.510 And uh it's very easy um, everyone can do it 2 minutes you just go
01:08:02.760 --> 01:08:07.040 IV and 2 minutes. I can, I can realise if you have some uh blood
01:08:07.040 --> 01:08:12.800 supply problem, blood viability, and then you convert to to retro pack that I,
01:08:12.840 --> 01:08:19.450 I think that's the problem comes at first in mastectomy for sure yeah
01:08:19.910 --> 01:08:22.259 yeah. Yes Question?
01:08:23.000 --> 01:08:27.209 This question comes from uh an online attendee, where Berner Hamilton Burr,
01:08:27.299 --> 01:08:29.930 who asks which ADM does Ashkhari use?
01:08:32.259 --> 01:08:38.209 I actually moved away from using biologics to using more of uh the uh.
01:08:39.100 --> 01:08:43.250 Titan titanize mesh, but again, it depends on why I'm using the mesh,
01:08:43.540 --> 01:08:46.740 what is the indication, radiation therapy is there or not there.
01:08:47.729 --> 01:08:51.229 Uh, it's not, again, like I said, you just can't say I use this.
01:08:52.549 --> 01:08:54.830 There are lots of idioms there. There's not much to choose from.
01:08:54.899 --> 01:08:56.410 You have meshed, you have non-meshed.
01:08:56.819 --> 01:09:01.220 I think what you need to understand as an audience is meshed integrates faster.
01:09:01.950 --> 01:09:06.410 And it's not the surface area, but the thickness of the ADM that gives you,
01:09:06.569 --> 01:09:09.529 sorry, it's not the thickness, but the surface area of the ADM that gives you the seroma.
01:09:10.398 --> 01:09:13.479 So these are the things that you have to take in when you've got palpability you need you
01:09:13.479 --> 01:09:17.219 need a solid ADM, something thicker, maybe that helps.
01:09:17.559 --> 01:09:20.628 So I use every ADM that's available depending on the patient.
01:09:20.838 --> 01:09:23.958 Uh, may I add something? I think that it's not my topic,
01:09:23.999 --> 01:09:28.458 but it's something that, uh, I want to, to, to tell you.
01:09:28.918 --> 01:09:32.668 Uh, if you compare a retro pack versus prepack with ADMs,
01:09:32.679 --> 01:09:37.159 better prepack with ADMs. If you compare prepack with ADMs and seroma
01:09:37.159 --> 01:09:38.758 because we have erro with ADMs.
01:09:39.509 --> 01:09:43.299 Uh, versus no ADMs and prepa, I prefer I would go to,
01:09:43.629 --> 01:09:47.470 uh, to a good mastectomy, pre pack no ADM.
01:09:48.149 --> 01:09:54.169 This is the the the the best way to do becau but, but of course this is not evidence based
01:09:54.169 --> 01:09:56.290 medicine it's necessary to have a trial.
01:09:57.509 --> 01:10:02.009 And it is possible to do a trial. ADMs versus no ADMs on pre-pack reconstructions,
01:10:02.660 --> 01:10:09.020 and we are helping that somebody here does this trial and give us the answer,
01:10:09.140 --> 01:10:14.600 the correct answer. Yes, you, I also ask, but he's moving away from
01:10:14.600 --> 01:10:15.979 ADMs. Is it possible?
01:10:16.060 --> 01:10:21.259 Is it possible to randomise patient in this because this is also very relevant the patient
01:10:21.259 --> 01:10:23.979 selection, you know. For example, you, we,
01:10:24.229 --> 01:10:29.149 together with Mauritzianava, we always follow an algorithm for going for a prepectoral
01:10:29.149 --> 01:10:32.740 approach, um, according to the Rancati score.
01:10:32.950 --> 01:10:39.589 So we opt for a prepectoral approach also without ADM when we have a type 2 or uh or a
01:10:39.589 --> 01:10:44.350 type 3. Firstly, we went for prepector only for type 3
01:10:44.350 --> 01:10:49.430 when we had more than 2 centimetres of subcutaneous tissue of laminar fat over the
01:10:49.430 --> 01:10:51.069 anterior layer of the capsular ma.
01:10:51.740 --> 01:10:57.299 Now we move to a prepector approach also when having from 1 to 2 centimetres,
01:10:57.359 --> 01:11:01.919 but I I would not go for a prepector approach for a type 1 breast,
01:11:02.060 --> 01:11:06.740 having less than 1 centimetre assessed before my procedures,
01:11:06.779 --> 01:11:10.459 so also during the, also during the uh the procedure.
01:11:10.830 --> 01:11:16.810 But I know that you would go for prepeor also in this case also for very thin
01:11:16.810 --> 01:11:20.580 flaps because I didn't read the paper.
01:11:22.689 --> 01:11:25.919 All right, yeah, I got a whole list of questions, but we've run out of time and I
01:11:25.919 --> 01:11:27.640 think we're gonna have to move on to the next session.
01:11:27.680 --> 01:11:29.899 So I'd just like to thank the panellists for really a,
01:11:29.919 --> 01:11:30.600 a very interesting.