Let's go to move to the next topic about implant exchange synesthetic surgery Isabel de
la Pena. He was here, ah, you are here, perfect.
I see.
Well thank you very much good morning to everyone and I'm sure we all agree that uh
breast augmentation is probably one of the most commonly performed cosmetic surgery in order to
gain the perfect size and the perfect volume distribution for women.
But one of the most important, uh, decisions that surgeon has to done when you're performing
a breast augmentation is in which anatomical plane you're gonna place uh the
implant because this is gonna have a lot of uh.
Uh, I, it, it includes a lot of decisions that comes with it and definitely one of the most
important is that when you see in a let's see from a resident
standpoint of view.
The possibility of having problems or having not as successful after a breast augmentation,
the possibility of having complication, it's a lot more higher when you go in the sub muscular
plane than when you go in the subglandular space.
So this means that if we take capsule contracture away from what we're speaking,
then. The possibility of having trouble on
unsatisfactory uh results with breast augmentation is when we use the sub
muscular plane and we do we do not have the perfect way to do it so.
Once we have said this, uh, the causes for unfavourable results of some muscular space
is basically when we're speaking, uh, if we do not have the perfect ratio in between the gland
and the implant volume that we're gonna be using.
And of course if we don't prevent the dynamic alteration that the breast is gonna have after
placing the implant and obviously we will we will have the possibility of having seen nasty
I go all the way in the middle part in the middle part of the.
Thorax and we always will have the possibility of having displacement of the implant
because the forces of the pectoral muscle on the central part on the medial part close to
the sternum is a lot bigger than on the lateral part.
And we had and if we had more dissection in this area we're gonna have more displacement so
I think that when we get older we are just having all the problems of the patients are
having so they come with us and here we can see a perfect example of what uh
dynamic alteration of the breast uh you can see.
And basically in this patient we have two different ones because the the implant is going
on the lateral part but we have uh dissection on the on the breast and we have
a little bit of bottom out in in this patient so.
I think that uh on satisfactory results when we place the implant in a sub muscular space
requires much more uh skills during surgery in order to prevent all of these ones.
So once you have it, how are we gonna manage this kind of uh problems.
Basically, the, the, the principles out we're gonna exchange the implant we're gonna try to
reinsert the pectoral muscle we're gonna exchange the implant into the subfacial or
subglandular space and I believe a lot of times we will need a lot of skin adjustment.
So here's just one of the patients that we receive very commonly.
And you can see that we have a problem for us a dynamic point of view,
but even if the patient is not in movement, she still have,
uh, a non-desirable result.
So, uh, we're gonna try to do an abdominoplasty at the same time that we're gonna do,
uh, we're gonna be doing this so we're gonna have, uh,
some fat to place in this position, but here you can see.
What I was talking, once uh we resect the implant we have to divide the volume of the
gland because the volume of the gland is so big and the implant was so small that there was a
big discrepancy in volume in both sides.
So once you take care of the capsule that we basically resect the capsule what I'm gonna
do is I'm gonna design where is the uh lower part of the pectoral
muscle. And so I'm gonna take the capsule out.
I'm gonna deal with the capsule and I'm gonna draw where the distal end of the pectoralis
muscle is, and once I have it, then the next step is that I'm gonna try
to reinsert the pectoral muscle in the place once we took care of the capsule,
obviously, and then we start placing.
And with the barb suture we are reinserting the pectoral muscle in its original place.
When we do this we're planning to do a complete, uh, lift of the of the gland of the
mammary gland in order to place the new implant.
So once we finish doing this, then we're gonna be able to place an implant on top.
Of the muscle and then we're gonna use these 3 different flaps that we have the inferior
pedicle flap and the 2 lateral ones in order to build a gland and a uh and a and a
breast mount that is gonna be perfect in terms of the size of the implant and the size of the
volume of the implant that we're using so we have the possibility of doing this kind of.
Uh, movements in the anatomy of every patient, so the possibility of achieving the best result
is easier.
So, uh, here we have solved the problem of the unsatisfactory, uh,
dynamic problem of the breast, but at the same time we have the possibility of moving these
parts where the implant is is specifically the lateral part where the implant was having.
Here I have a patient that I've been following. I did a mastopexy 10 years ago.
She came back. She had one of the implants.
She's ruptured, so we're gonna exchange the implant, but finally she decided to go
somewhere else and do the surgery, and she said she came back to me and see if we can
solve the problem that she gets, uh, after surgery, so.
In these cases, uh, we really have to do a lot of things.
We have to change the plan, but we have to decide where are we gonna place the
inframammary fold because we're gonna keep this inframammary fold,
so we're gonna raise them from mammary fold.
We're gonna exchange the implants we're gonna exchange the anatomical plane.
Where the where the uh implant test obviously she had uh a lot of problems with
the right areola that we will be tattooing at the end of uh of the surgeries when we finished
with all this programme.
And here you can see that once we resect the fibrous tissue that she had there because
she, she had a lot as as the alveola have a vascular problem also the uh the glandular
tissue had a vascular problem.
So once we solve this, we reinsert the pectoral muscle and once we reinsert the pectoral
muscle now we're gonna be raising the inframammary fold in order to get a better
position for this and.
Uh, when we finished we have the possibility of putting an implant in this area and when you
see the pre and the post-op you will be able to see how much do we be uh able to raise
the inflamm fold in order to get a better position for this,
uh, patient, so basically.
Uh, I, I think it is, uh, sub muscular plane it's a great plan for implants and it
has a perfect indications, but I really think that, uh,
it's a decision, uh, that we have to do with our patients in order that they understand what
we're doing. Uh, this is another patient that has obviously
and dynamic alterations, but also she had a problem on the left side that you can see
making hollow in the in the inferior pole of the breast.
So in cases like this that the skin is not looking good,
I prefer to stage the surgery. So what do I mean by staging the surgery?
This means that I'm gonna uh be replacing the muscle in in its position at the
same time I'm gonna be closing all the areas that seem mass that she had and once we do this
I'm gonna close. I'm gonna put all the tissues in position and
then I'm gonna try to refer here you can see how the uh pectoral muscle is in this patient.
I mean it's very hard it doesn't move at all so how can we restore this
muscle and put it back in position? Well, one of the great things about having uh
fat in these patients is that we can transfer fat directly to the muscle and then reinser the
muscle, use the mesh in order to maintain everything in position,
then put the the the the glandular tissues back.
And once you have the glandular tissues, here's how we do the uh restore the reconstruction of
the pectoral muscle we're putting some fat on it and once we finished doing the fat and
putting the mesh and closing the pectoral muscle in in position,
we have the possibility that.
To add a little bit more fat in the subcutaneous tissue and on the gland and once
we do this then this patient uh I was going to stage the surgery but after
surgery she was so happy with the result that she didn't wanna come back and do that.
The breast augmentation again, but obviously what we're looking here is that we have the
possibility of restoring the pectoralis muscle to restore the gland uh the glandular tissues
and obviously when you transfer fat to the skin it also get a very nice contour after the after
the surgery. So, uh, capsulele contractor is definitely uh
uh one of the worst things that can happen when we're dealing with this,
but certainly the kind of implants that we're using nowadays are a lot better than the ones
that we were using on the 90s or in the end of the 80s,
and here I was invited to Moscow in order to perform surgery for one of the meetings and
this is the patient that was selected for me, so I really thank them.
For having a patient that was so easy to restore and uh so uh she
obviously had the implants placed in the sub muscular space and you can see that there a
dynamic alteration in movement is amazing and in this kind of patients I mean she
was in in Moscow. I was in Mexico how can we get together in
order to tell them what to do, what would be the right.
Uh, size of the implants, so using, uh, artificial intelligence is probably the best
way so I could send her some of the options that I can have in order to move and see what
the what the volume that she had and what I was thinking about moving all this so I told her
that I have to do, uh, of course, uh, she needs scar in order to fix the problem and.
Obviously, uh, we took out this, uh, implants that had no no brand but
finally we take it out, we take care of the capsule and as I was telling you I use mesh in
all these patients in order to have everything in position back and do not have symnastia and
all these, uh, movement alterations and here is, uh, when I'm fixing the the mesh.
And how we're bringing together all the tissues and now uh this is uh the post op that they
sent me back and she will need a scar correction for the areola but definitely uh the
inframammary fold position is a lot better. She doesn't have any kind of uh muscle
alteration or dynamic alteration when when she's moving.
And fortunately the the possibility was great and then we have all these spaces that still
having in the sub muscular space but the but I was telling you if you we don't have a nice
ratio in between the volume of the gland and the volume of the of the.
Implant it is almost impossible to to have a very nice result so this patient had a very
good coverage for the implants so there's no necessity to put the implant in the sub
muscular space.
I replaced the muscle in position and once we do this we have the possibility of a change,
do a small breast, place an implant in the subglandular space and obviously get a lot
better, uh, position.
And we, we did the, the, the liposuction of the of the abdomen at the same time.
So changing the implants I think uh we all surgeons must uh
understand what we're doing when we're dealing with the implants and when we're dealing with
the anatomical uh patients so we know that. Uh, everybody have a
different approach for implants. I really love the polyuretine cover implants.
I never had this, uh, alterations that I showed you at the beginning with the capsule
contracture on the, uh, on the silicon cover implants.
But I think that with the right understanding of patients anatomy implant characteristics and
aesthetical goals we can make informed decisions regarding the anatomical plane that
we should use in order to fix all these problems that we all have,
uh, in this. Patients we can see that the pec muscle is all
the way up and we have to restore this and probably there's no other way to do it that
using the mesh bringing everything down and in this case I have to close the the
the external part because it was.
Uh, almost the same massive from one part we closed as I was telling,
and a lot of the times I've been using the capsule in order to bring all the muscle down
and try to fix it into the inframammary fold and so all these,
uh, anatomics and displacement that we have with the with the patients can be solved if we
replace everything in position and exchange the implant, of course.
And some of the times I have to use either a mesh or an ADM in order to
achieve the perfect results, especially when I'm dealing with breast reconstructions and in
breast reconstruction, the use of ADM and even using a dermal fat grafts from the same patient
can allow us to have a better result and a better coverage for the for the implants and.
And this patient, for example, this is a patient with uh 15 years follow up of uh
polyure and cover implants we never had the uh the chance to change it because.
Obviously during the next 15 years the evolution was great so uh the ability to adapt
and change anatomical planes will offer patients even more customised and satisfactory
results but I think it's our, uh, decision which plane are we gonna use and how to do
it. Thank you very much.
My pleasure. This very nice lecture.
Um, some questions.
Um, In your technique, obviously you have this lower flap.
Are you doing this only in patients who had previously the augmentation done by a
periareolar incision, or do you also use this technique in patients who have had an IMF
incision previously?
Previously, yes, I tried to use the the incisions that they had before.
But there's a lot of patients that you really need to,
there's a lot of skin excess and you have to redo it that's why you need the inverted tea in
order to fix the skin because it's just like you're uh the laminating the whole breast so
you're gonna take the skin in one part, the muscle in another part and the breast in
another part, and a lot of the times what I tell the patients is I mean.
If I'm still using your breast as a whole, it's gonna be much more heavier than if I use
an inferior pedicle and a two lateral pedicles this way I can fix them to the to the mesh and
then it's not gonna be as heavier as if you take it as a whole.
But uh you don't, and you're not concerned that if somebody has had a previous incision there
that you, your flap that you're creating will not be well vascularized or even.
Uh, I, well, I've never had a problem with this, but I think that when it happens more when it
has passed more than 5 years that you have, uh, a surgery done,
then revascularization of the flaps is, is very common.
So I mean I don't think that's an issue if I would have a patient that had a.
Big problem with a very pre uh uh a surgery done less than a year probably I will make
some uh uh MRI's with uh contrast in order to see if the flaps are in good position but
basically patients come back after years having a bad result and then you have to solve it with
this and not, not, not having any problem, especially if you're using.
I mean when, when I try to place the areola in all the upper pole I mean I'm not using the
lateral part, not the middle part, not the centre.
I use the whole upper middle and larger.
Thank you. Questions From the audience
I really enjoy your presentation mainly because you show how to combine different techniques
and the concept of this muscle reposition going back to the normal anatomy but they show
fat grafting putting fat grafting in the muscle in the same moment that you make this
reposition. Do you think this is worth it because normally
there is some kind of a trophy in the muscle.
A lot of atrophy, but you know you have the muscle there.
I know that uh you know with all these, uh, big issues that happen in the United States with
the with putting graft in the gluteal muscle that it's a big problem,
but the problem is not in the gluteal muscle.
The problem is in the veins that goes to the iliac part of the circulation.
So you have the muscle in front of you and it's a traffic the muscle and you have to
restore it. So I mean you have the muscle you place exactly
in between in the muscle and the fibres you can be placing the the graft and the muscle is
gonna be restored.
So no, I. The concept is you, you put the, the,
the photograph not to get more volume you you more to repair the muscle to repair the muscles
clever good one question Andrea.
OK, thank you. It was really, really interesting talk um I
results are beautiful. I have a question, so most of my cases are
actually reconstruction. I do breast reconstruction much more than
cosmetic breast, but I think all the techniques apply.
Um, sometimes when I have patients who had some muscular.
You know, uh, reconstruction and they have bad animation deformity and we do a plane
change. We don't have the capability of developing that
flap if there's not excess tissue on the breast, um, so many times what I do,
I reinforce with4HB just because I feel that for
reconstructive patients where you don't have a lot of tissue to support that implant if you
don't reinforce that lower fold, you will have a.
You know, a drop of that implant over time and stretching on the skin and I wonder if you have
used uh before HB in any of these cases to help to reinforce it.
Yeah, no, 11 of the, uh, when I received the patients and I still do a lot about breast
reconstruction, so the first thing that I always try to find in,
in specifically in these cases like you're speaking is if I have the possibility of
getting a dermal fat graft from the abdomen.
And most of my patients because are about the 50s, so they still have a little bit of excess
in the lower part of the abdomen so I prefer to tailor a uh dermal fat graft and put it
in in the lower edge of the of the pectoral muscle and fix it to the inframammary fold
and so that's kind of my my first kind of option.
The second one is using the mesh that I normally use and I've been using it for 10
years, which is 50% absorbable.
It's polygecarone and uh polypropylene, so 50% is absorbable and
as I've been working with this for 10 years and never had a problem.
I think it's a great option and the other is, I mean if the patient has enough money to pay the
ADM then I'd probably go with the ADM.
Thank you. Thank you very much for this lecture and uh for
the questions. I think we're gonna move on for the next
session and we're gonna hand over to the next chairs.
Be me.