Greetings. I'm Dr. Bob Murphy, and it's my pleasure today to welcome you to the ASPS Global Partner Webinar Series, today featuring two tremendous colleagues and very talented surgeons from the Brazilian Society of Plastic Surgery, Dr. Ricardo Ventura Herrera and Dr. Osvaldo Saldanha. First, I'd like to bring to mind some ground rules. Next slide, please, Amy. If you're going to submit some questions, please be sure to use the chat section at the bottom of your screen. We'll answer as many questions as possible. And also, please note that today's webinar will be recorded and posted on the ASPS EdNet for those of you who are ASPS members. For those of you who would like to access this, please contact Ms. Romina Valadez at the email address you see. And we'd be happy to have a conversation about how to make this accessible to you. Amy, next slide, please. So today, again, we have two wonderful speakers. Our first speaker will be Dr. Ricardo Ventura from the Dominican Republic and Brazil. Dr. Ventura is a plastic aesthetic and reconstructive surgeon who is based in the Dominican Republic. He completed his specialization in Rio de Janeiro, Brazil, under the guidance of the renowned Professor Ivo Pitengui. Dr. Ventura is a pioneer of the lipobaser and lipodefinition technique in the Dominican Republic. He is an international speaker for vaser and rejuvenation. He currently is the titular professor of body sculpting course and is an international visiting professor of the residency program at Serviço Plástica Osvaldo Sardana in Santos, Brazil. Dr. Ventura is a member of ISAPS, FILAP, and is an association of the ex-students graduate Professor Pitengui. He is also a member of the Dominican Society of Plastic Surgery. So with that, we'll turn to a pre-recorded session of Dr. Ventura's technique, and we will have questions and answers at the end of both presentations. Hi, everyone. My name is Ricardo Ventura. I'm a plastic surgeon from the Dominican Republic, and I want to show my appreciation for the invitation to this webinar to ASPS and, of course, to Dr. Robert Murphy, who is also our moderator. It's a pleasure for me to share this webinar together with my great mentor from Brazil, Dr. Osvaldo Sardana, and thank you for everyone that has connected to attend this webinar. For the next 15 minutes, I'm going to show you sculpting techniques in order to get a proper and nice 3D body contour. And by the end of this webinar, we'll be answering all your questions. So please, feel free to submit your questions to the Q&A box during this presentation. So let's start by talking about the marking of the abdomen. We're going to design five negative anatomical units, which are responsible for a three-dimensional shape of the abdomen, and we started by dividing the abdomen in two. Afterward, we're going to design the transition zone between the oblique muscle and the rectus abdominis muscle, and as well as we design, as you see here, the proper place for the incisions of the pubic area. Now we are designing the inferior oblique triangle and the waistline in order to have a proper and nice body contour. And afterward, the inverted triangle underneath the breast. So the main negative anatomical units is the anatomical unit one, which is the transition between the oblique muscle and the rectus abdominis. And this one is a slightly curvy line that goes from the tendril at the costal angle level to the iliopubic eminence. But this can be tricky for some surgeons at the very beginning. So you may see patients or models like the left one that has a more prominent inward transition zone between the rectus abdominis and the oblique muscle. And the reason for this is because they have a really strong internal oblique muscle, like this patient right here. But this is not the common case for everyone. So you may want to look this transition zone more outwards than inwards. And a common mistake for a lot of surgeons is to start doing this line as a straight line and really inwards in the abdomen. This may look quite fake as it should be placed a little bit more outwards, as the transition zone is more outwards. So you may have fake results like this one, or like you see in these pictures when you do this transition zones more to the inward place. The key point for this is to mark the internal muscular edge of the external oblique muscle. So how do we scope these lines? We have it already designed in the proper place, now we have to scope it. The first step is to devote the deep and superficial fat of the triangle. Afterward, I'm going to scope every border line of my design here. So I use the drilling maneuver, as you can see, I have taken my cannula all the way through the border of my design and scooping, going backwards with the tip of my cannula and with my artistic hand, which is the left hand, I'm touching the tip of my cannula in order to be more precise where I am doing this, the Vulcan. The tourbillion maneuver is also another maneuver that helps me to get and improve my resolve of this definition in these lines. So I use a Mercedes tip cannula and cannula that goes from 15 centimeters to 36 centimeters and not more of a diameter bigger than three millimeters to four millimeters. Now we go for anatomical unit two, which is the linear alba, and you're going to get a better definition of this area if you don't have a siphon process. So if you don't touch it, you will have a better definition. Then again, the drilling maneuver, you take and do two tunnels here and preserve the central portion of this linear alba in order to get a better retraction. So you get these two tunnels separated. Also, you get help with your artistic hand like I'm doing here. Anatomic unit seven, which is the infra-umbilical fat path. And this is quite important because most of our patients that want a flat abdomen right here, but it's not about the fat pad only. It's about the anatomical structures here. So most of our patients that will have an eye parlor doses here and a weakness of the inferior portion of the abdomen. So what I have tried in this patient is to break the roundness by doing a definition of the central abdomen that I have found in some models that they have a different distribution of the fat pad here. So I make this small and thin growth here definition in order to get a better retraction of this central portion of the abdomen. As well, we like to treat this area in the direction of the rectus abdominis and also using this adipometer as you saw in this video in order to get an end point of 0.8 to 12 in the positive area millimeters in the positive area and a 0.3 to 0.5 in the negative area. This is my end point for the negative areas that I have the definition here and for the positive area which are the rest of these transitions anatomical units. So that's how we get a proper transition zone and a good retraction in always respecting the no-go zone or the addition zones right here in this place. Also talking the muscle in the inferior portion could be helpful for those patients that have a great weakness of the inferior abdomen, even though if they don't have kids sometimes they have a great weakness and by talking the muscle here in the inferior portion we get a really good result in those patients that they complain about the shape of their inferior abdomen. Finally, I like to treat this area using my light of the OR as we see it in the natural environment we can tell when a patient has really nice results or when they have irregularities. So I can identify these irregularities by using the lights of the OR. So five rules for dealing with the inframedical fat. Do not cross tonal. Respect the direction of the muscle fibers. Collapse the infracentral abdominal line. Respect the additions areas. Talk the muscle when it's indicated and use the lights and shadows to evaluate the final results. How to get a lipodefinition of the back and gluteal contour. So the first thing is that we need to understand that the back we need to get it with soft and curvy transitions. The sacral region is not totally flat as you can see here they have a three-dimensional shape. Glutes are not just round they are more like teardrop shape and we have to do all this without any visible incision. So let's start by doing the markings. The first markings I like to do is the posterior iliac spine, the erectus spine muscles, the definition of the upper portion of the gluteal, the iliac crest, the transition between the gluteal medium and the gluteal maximum, the border of the costal angle and here I'm doing the design for my fat transfer which always have to begin with the frame of the gluteal which is the most important thing and afterwards I'll see if I need any projection right here at the center of the buttocks area. This is quite important to do a maneuver of this expansion maneuver to see and do the evaluation if I can actually correct it if the patient has the expansion here in order to put the fat in this transition portion. So these are my markings and we're going to start by designing the anatomical unit one which is the erector spine muscle and the sacrogluteal transition. So these are my negative units here. The erector spine muscle is a group of four muscles but is only two of muscles that goes all the way to the bottom part of the glute of the back and as you can see we're trying to do a three-dimensional shape and then again we use the drilling maneuver in order to get the proper and the specific areas that we want to debug superficial and deep fat. Also the tourbillon will help me to get the fine details in this area. A short candela will help me to debug the deep fat at the transition of the gluteal and the sacral region and my artistic hand that we can use the palm, the claw, the thumb and these are a few maneuvers that will help us in order to get the proper debugging of this area right here. So these are the results for a three-dimensional in a fit patient. As you can see she didn't have this in definition even though she had really good muscular definition and now that she has this definition it looks a lot more beautiful. Now we're going to show you how to do the bulking of the fat pads at the top of the back without doing visible incision. So this way it will look a lot more natural as you see here. So we're going to treat this blue section here without using any of these incisions on the back which looks a lot more natural. So we start by placing our patient in a superman position and we place the incision at the posterior axillary line really well hiding inside the axillary posterior line and we use a candela mercedes of 36 centimeters it could be three or four millimeters. And as you can see we do a vertical debulking of this area this helps me to get a better and proper retraction of the skin. So this is our patient today. This is a common patient that we might get into our office and what are their usual concerns? The usual concern is the fat pad here at the top of the frame of the gluteal and also a depression of the trochanterism right here. So let's see what else we can do for our patient. So the main thing is to correct this fat pad right here as you can see when we correct this fat pad right here and we work out the transition between the gluteal muscle and the frame we get to correct and have a nice body contour. So how do we do this? We can actually use the pore of the sacral portion with a curvy candela. Also we can go for a small incision to this lateral portion in order to get also the proper debulk of this area. It depends on how much fat this patient has. The important thing is to avoid any harm of the skin with the tip of our candela. So be careful with this. You can actually get a really good result debulking this area by using the sacral pore but you have to be careful with that. So let's start by studying a little bit more about this patient and she has her gluteal muscle here and as you can see she has a really long intergluteal crease because she has some fat pad here. This angle should be of 45 degrees. She has a 90 degrees and also she has some fat pad at the inner thigh. She's also missing some fat pad at the transition zone and at the frame. So she has a more as a square frame right here in this place and she has more as a name frame right here in the other place. So they're not equal and this is something that we must tell our patients before the surgery. So let's take this patient to surgery. The first thing is to collect the fat. Of course I use a machine in order to a bump in order to push my fat through my candela. I bump the fat. It helps me to do it faster and also to make it easier to sculpt. And here I already did the transition zone between the gluteal and the frame and now I'm doing the projection of the gluteal. So I want to push my gluteal to the middle portion so I get this fat in the deep plane of the of the fat at this central part to get the proper projection. Also I have to treat this fat right here at the infragluteal fold and this is something that gets you into a better shape of your gluteal. It's quite interesting to do it and most of our patients they need to do this and I devote the deep and superficial fat of this area right here. So this is how we get this result six months later. You have a proper space here, a proper angle of the infragluteal fold. Also a smooth transition between the gluteal and the frame as you can see here and you have a more equal frame between both sides. Respect always the transition between the back and the gluteal. This is quite important in order to get a good result and as you can see we don't have a round shape gluteal. We have more like a teardrop shape. This is our post-op routine and as you see here we are using a shirt, pumpers and also a vest in order to get a proper compression of our garment. Is this for every patient? No this is not for everyone. Actually our patients they need to understand that they have to take care of their diet, their lifestyle and this is something that we have worked out in our social media showing and being an example for our patients for a healthy lifestyle and also we show in our social media, in our Instagram account, how our patients accomplish their results by not only doing surgery but also by having a healthy lifestyle. I want to show my appreciation to Dr. Saldanha and Dr. Benjamin. We have together created a group for a training course which is called body scooping in Brazil, Sao Paulo and these old techniques we have developed together in order to show the surgeons and to everyone that you know attend to our webinars how to do a proper and a safe and get natural results with these techniques. Thank you for everyone that attended to this webinar. And I'm here for any questions that you may have. Well, thank you, Ricardo. I mean, those were absolutely spectacular results. So I would suggest that both of your hands are the artistic hands in this case. Wonderful, and I'm sure we'll have lots of questions after our next presentation. So at this time, it's my privilege to introduce Dr. Osvaldo Saldana, who is not only a world renowned plastic surgeon, but I consider it a dear personal friend. Dr. Saldana has actually taught me through his writings how to do a wonderful abdominoplasty that I pass on to my trainees even today. But Dr. Saldana is the chair of plastic surgery and the head professor of the Department of Plastic Surgery at the Universidad Metropolitana de Santos. He is the past president of the Brazilian Society of Plastic Surgery and the director of the Department of Accredited Plastic Surgery and the service coordinator of the Sculpting Academy, as well as a reviewer for our own plastic and reconstructive surgery. So with that introduction, I'll turn to Amy to present Dr. Saldana's work. Thank you, Dr. Saldana, my dear friends. I'd like to thanks to the ASPS Society, especially in the name of from Dr. Robert Buff, and it's a good pleasure to share this webinar with my friend Ricardo Ventura. I have no disclosure to say, and now let's talk about live abdominoplasty up to date. Now it's called live abdominoplasty with anatomical definition. It's very important to visit the past because we discover some interesting things. For example, this patient that I operated in 1981, I could see that this patient has a low definition, especially in the semilunar area and in the alveolar area. It's happened because in that time, we didn't do liposuction while we perform abdominoplasty. So we didn't erase the anatomical muscles definition. In 2000, we discovered the live abdominoplasty, and because the perforated vases preservated, we could begin to use liposuction safely. And we can discover also, and the most of the patients, they present some kind of definition because we usually, we don't do a strong liposuction when we perform liposuction in live abdominoplasty. And another case that we can see, a low definition in the abdominal wall, but some cases we observe no definition. What's happened? We do a strong liposuction and we erase completely the anatomical wall of this patient. So these results, we need to avoid it. We need to observe the anatomical definition of the abdominal wall. It's changing the concept of the abdominal looking. Dr. Harry Metz was the first to publish the definition of abdominal, he called abdominal etching, and he published in 1993. But this paper, where the plastic surgery community began to understand this concept 14 years later. So Dr. Hoyos, Dr. Ventura, and many others, plastic surgeons, using this concept and spread the technique in the world. For live abdominoplasty, the goal that we understand is to obtain a medium and low definition. No high definition, because the concept is different. Then we began to introduce this concept in live abdominoplasty in 1960. But it was Dr. Ventura that made us to understand exactly the obvious. What's the obvious? Before I know him, I thought that we needed to make a fake definition. How is that? Because I understood that we need to make simulation of the fat to simulate the muscle. But it's not happening. It's exactly the contrary. We need to remove the fat for us to see the abdominal muscles. So it's exactly different of the concept that we had before. In live abdominoplasty, to make it easy and to avoid complication and to have a patternization of the markings, we divide the abdomen in four zones. The first one is the light green zones. They correspond to the side edge of the rectus and the flanks. Here we use a usual liposuction. The second one is dark green zone that we do in this zone, a strong liposuction correspond to the semilunar line and the oblique transition. And also the central area of our line. The yellow zone correspond to the area that we go to down and substitute the inferior abdomen. So here we need to do a careful liposuction exactly as we need to do in red zone that correspond to the areas where there are the perforated faces. And the last one is the black point that is correspond to the future position of the umbilical. So we need to do a strong liposuction from this point to up and not to down. But it's very important to call attention that when you use a lipoabdominoplasty with definition, we need to have attention to preserve the perforated faces to avoid complication and especially necrosis. Another important thing is to observe when you do an examination, you have the exact position of each part of the muscles because we need to do exactly point the markings. So we can see here in the lipoabdominoplasty marking, we can use the markings from Dr. Ventura marking, but we can use all of the areas and the region that he do because the abdomen will do releasing to down to the pubis. So this area will move of the region. So we can use the strong liposuction to have a negative area in line one, semilunar line and the alba line and also the inframammary region, the number five of his marking and also the flanks that correspond the number four. And also we can use exactly the marking from Dr. Ventura because we need to have a very, very important definition between all areas that we do liposuction and showing the limits from the gluteus, the flanks, the sacrum region and especially the midline of the dorsal. We begin the surgery in the dorsal looking for definition of the gluteal area and the Michaelis triangles, looking for the cannula with three millimeters caliber and defining and this link of the gluteus of this all region of the dorsal. The most of the time we do fat graft to have a harmonious areas between all region of the dorsal and to have and define the limits between the gluteal and the dorsal and the sacrum and the flanks. Usually we do about 300 CC in each side of the gluteal. As we can see a harmonious line between the glutes and the ovary of the dorsal. In the abdomen, we began to have infiltration, 500 solution with two CC of the adrenaline and we infuse about 1,500 CC or a maximum 2,000 CC. I put the patient on the pillar position. It's a very safe position for the cannula, not too down, too up and begin the liposuction with the three millimeter caliber cannula and changing for the four millimeter caliber cannula. We begin to the negative air, semilunar and the alba area. Letting about 0.5 centimeter of the mixture of the skin, the subcutaneous tissue and looking for to define all part of the muscle as we can. The area five of the Ventura definition that we can promote a very special negative point between the area one and five. And after that, we begin to make liposuction in the positive area. Carefully, I use in this area only the three millimeter caliber cannula, not four or five, because you need to preserve the perforated vessels. And this positive area, we let about 1.5 or two centimeters of the subcutaneous tissue. Next step is the incision and definition. The incision, suprapubic incision. And we are preserving the scarpa fascia in the inferior abdomen and removing the fats, the deep fat layer and the scarpa fascia exactly in the middle part of the inferior abdomen to see the muscles and to complete the placation. And then, as you can see here, here is the muscle fascia and here is the scarpa fascia. The next step is to isolate the umbilical pedicle. And the sequentially, we begin to undermine the tonio look, the perforated vessel we need to preserve. So it's important to overpass the internal border of the muscles, because from this point, we can cut the important perforated vessels. Next step is to make the placation. We use a strata fix to do it. It's very interesting suture. You can do a continuous suture. And when you reach the umbilical position, we isolate this area and continuous the placation in the inferior abdomen. Exactly the measure of the diastasis. We don't do over-placation. Sequentially, it's important to call attention that it's a very nice position of the umbilical pedicle is to put it so as deep as possible because it's important that the umbilical pedicle doesn't go out. The skin of the abdominal wall needs to go down and make the scar very, very high. We use the star-shaped omphaloplasty. This vertical incision correspond to two centimeters and the horizontal incision about one and a half centimeters. We continuous doing four subdermal suture between the skin of the abdominal wall and the pedicles. And we, the next step is to remove the four corner of the little flaps and make another four subdermal suture to approximate the skin, the abdominal wall and the pedicle, umbilical pedicle. And the final of the surgery, so showing as deep as the umbilical position. We can see it in this in another patient, the deep position of the umbilical. And to avoid complication, we use a selection of the patient. We request ultrasound the abdominal wall to discover some hernia without any symptom. We use against the DVT compression stocking, thermo-temporal compression, low molecular weights, heparin and yield ambulation. Pillar position is important, I told before and a selective dermal is the goal. We have maintained a low rates of complication, especially about the necrosis that we decrease from 4% to 0.1, if you consider abdominal blast and the live abdominal blast. I am very proud to receive this best paper award of the PIS in 2021. And you can see here some cases. It's correspond the patient from the 2017 when we began to use this concept, we have a very, very natural looking of the abdomen but not too strong definition. We will increasing the liposuction and more strong than we do before. And we have now a little bit more definition of the abdomen, the liver area and the elbow area. Another case is showing that this is my resident cases that we can show that is the reproducibility very, very easy all residents doing exactly like me. This patient can see that although she has no good scar but she has a very nice look of the abdomen and it's not correspond to stigma of the abdominal blast. Another one, and this another patient showing the natural looking, especially when you consider the umbilical scar. Thank you so much for attention and we are waiting for the questions. Again no surprise Dr. Saldana how expert your technique is to deliver such wonderful results so thank you for sharing with us all today. We'll go to the chat box for the first two questions um and Dr. Dover asks can both of you speak of any of your most common complications that you've encountered? Maybe Ricardo you go first. Yes sir um well thank you for the question. I think local complications we can tell that at the very beginning we started getting some of our fiber cords and those fiber cords we started treating it with uh at the very beginning just with massage lymphatic drainage compression and and some dynamic movements you know you you send your patients go back home you know and stretch stuff so that way it will disappear within a few months. Then we we also added to this treatment the third generation of ultrasound which is uh which is a venus legacy is a technology that give that can help us it's not ultrasound actually it's um um it's uh what it's called um radiofrequency so it's a third generation of radiofrequency three polar radiofrequency which helps to break through those fiber cords and and get you better. And I think the other one it's seroma so seroma where they come from time to time as well and you just drain it just have to drain it. How do we avoid it nowadays? We use um some compressions exactly at the negative area so these compressions will help me to avoid any liquid to stay over there and to form any kind of uh scar tissue so those are the but for time from time to time I get some those fiber cords so I guess it's part of the of the procedure as well. And then Dr. Saldana same question for you please your common complications. Dr. Saldana I believe you're muted still. I'm sorry. There you go my friend. Enough of my voice. Yes thank you. I got to decrease my complications when I began life of the operation in 2000. So I have a few complications like epitheliolysis very one zero point two percent and necrosis I have just one one a little little like a big epitheliolysis and maybe 0.23 percent of the seroma and irregularities is I have no more no more and I have a decrease the revision of the scar I decrease it to 10 percent to almost zero because I don't mind about the extension of the scar if you if you try to get a short scar you you can have a building in the end of the scar and the review could be higher. Very very good thank you. Well you guys have stimulated a lot of questions from the from the audience. Dr. Ventura do you use drains during your cases or if you just suture the incision? Yes I do use drains. I think it's quite important and the patients also recover a lot faster. We have seen the recovery time a lot faster. When you use vaser I think it's even more important. So we do use your drains. I don't use back drains but I use Penrose drains which helps me to drain a lot faster. It doesn't depend on the patient you know they just drain. It's a little bit messy though but with pampers and you know taking care of your patient at the office and giving the proper treatment over there it's it's okay. So I use it for three to four days. Thank you. Dr. Saldana one of our participants would like to know what type of suture you use in your placation and have you noticed that it ruptures at all? Has it ever ruptured on you? I had used until two years ago nylon two zeros in the separated stitches but since 2000-2020 I began to use Stratafix. Stratafix is a barbed suture. Zero it's very strong treat and it's you can use just one line to suture continuous. It will spend no more than two three minutes to do it and I do isolate suture with nylon. I spend about 10-15 minutes to complete. So I recommend this suture with Stratafix zero. You can do two lines but just one is enough. Very good. For as long as we're on the topic of sutures Dr. Saldana, do you use Buruti or progressive traction sutures during your abdominoplasty? No I don't use. Sometimes a few times I can use in the tunnel when the flap is not easy to pull down the flap and you can have a strong tension of the flap. I can use two three sutures just in the tunnel because all the rest of the abdomen you don't have space, that space. So it's maybe impossible to do the Buruti suture in this part of the abdomen just in the tunnel. Very good. Thank you for that insight. Question for both of you. How soon do you let your patients do fitness training after your procedures? For my procedure three weeks is more than fine and actually the sooner they get to train the sooner they get recovered. We actually see that they get better results when they start training sooner but I don't do any placations. We're just talking about lipo definition here. Professor Saldana. Yes, the patients stay in the hospital one day and I don't use drains. Just when the patient leave to home I remove the drain and the exercise I recommend one month later. It was the question? Yes, that was a great question. Thank you for taking care of that. Dr. Ventura, do you notice that you have any differences in your results if you use technology versus not technologically assisted liposuction? That's a great question and actually we have comparison of our results from the Dominican Republic where I use VASER and some other results without using VASER in Brazil. For example, it wasn't until a few months ago that they accepted VASER as a legal device to do surgery. We have been doing all these training course without VASER and we have seen that it's not depends on the technology. It depends on the technique. I have had even better results sometimes in patients in Brazil. It depends on the technique and it also depends on the quality of the patient. It doesn't depend that much on technology. Of course, technology helps. It makes my work easier but if a surgeon thinks that he needs technology in order to have a good result, he's mistaken. It all comes down to those artistic hands, doesn't it? Yes, it comes down to the artistic hands. There you go. For Dr. Saldana, how do you control the bulging in the upper abdomen? In your technique? The bulging in the stomach region, yeah? Yes. It's not used in my experience. I think it's because the way that I do liposuction because I needed to disrupt the connecting between skin and muscle. But if some surgeon can experience the bulging, he or she can use a big candela and make some devotion of the flap to accommodate the skin and removing the bulging. That's enough. Make the most of the time you can correct the bulging using this tip. Excellent. Thank you. Let me see what else we have here for Dr. Ventura. Ricardo, can you give the audience your three main factors for achieving a good result with your technique? Well, I think we already talked about it. I think the main thing is the interest of the plastic surgeon. I mean, there are plastic surgeons, I think, for face, there are plastic surgeons for body contour. You really have to love body contour in order to do a proper technique because it takes time. It takes patience. It's different when you're just doing the bulking and that's it of the fat. When you are scoping, it's another thing. So I think patience and talent of the surgeon is basic. The technique, of course, a proper technique, even if you like it, and you don't do the proper technique, you won't get the good results. The third thing we said is to choose the proper patient. I think that's fundamental. If you don't choose the proper patient in order to do this technique, of course, you're not going to have the good results that we have seen in presentations. And I would say that's it. That's the most important thing. Technology, like I said, is important in order to help the surgeon to make it an easier surgery, but it's not the fundamental thing. Thank you for that answer. Dr. Saldana, a couple of questions about the limits of your technique. What is the limit of your tunnel undermining? And then, after you answer that, I have one other question about a limit, if you don't mind. The tunnel limits must be must be the width of the diastasis. If you have 10 centimeters of diastasis, the tunnel could be 10 centimeters wide. If you have more or less, it's exactly the limit that I recommend. Because if you do, if you pass, if you overpass this limit, you begin to cut the vessels. Also, you can do a little bit more correspond to the third internal part of the muscle, no more. Excellent. And if we can ask one other limit, what do you consider to be the flap thickness limit? I recommend no less than two centimeters in the positive areas. In negative areas, it's very straight. You can do a 0.5, but it's not exactly the area of the muscles. I recommend no more than, no less than two centimeters, because you can trump the blood supply, subdermal blood supply. Great answer. And actually, that comes to another question. Have you ever used any Doppler ultrasound to mark your vessels that you must preserve prior to your procedure? Ventura? No, I think it's for you. That one is for you, Professor Saldanha. You're using the ultrasound to see the vessels. He wants to know if you use any Doppler. I request ultrasound pre-operatively, because we know that about 4% of the patient has a hernia, not big hernia, but there is a weak in the abdominal wall, and it could introduce the cannula, and it could be dangerous. So it's very nice to know if the patient has hernia or not, to avoid to make liposuction in that region. Thank you. One of our surgeons is curious whether with your abdominal plication technique, you've ever had a case of intra-abdominal pressure being... Intra-abdominal plication in the cavity? No, I don't understand. No, I'm sorry. When you pull the muscle tight, whether that makes too much pressure inside the abdomen? No? No. Okay. We just, we just go on to another one then. Do you, let's see, do either of you use any, any other substances like an acid or anything to make sure you don't have seromas? Do you use anything to spray on to prevent seromas? No, I don't, I don't, I don't use anything to prevent the seromas. I do use tramexanic acid in order to prevent hematomas or to prevent bruising, and it's been a quite good help. You see the patient the other day, they don't, they don't have, they might have a few, very few bruises or not at all. Dr. Saldana, anything? No, no NC. Let's see, I think most of the other comments are coming up to be congratulations for you folks for putting on such a, a wonderful, a wonderful session, but I'm just double-checking one other set, one other place here. Could you, could you also just re, let the audience know about that course that you are providing in Brazil? There seems to be some interest on some of the parts of the attendees to understand how they might get a little bit more experience. Okay, you want me to answer that Professor Saldana? You can answer, please. Okay, thank you. Well, this is a training course for, it's a hands-on course, it's for eight surgeons. We have a three days training course, which is the first day is of about just theory, just a master class like we, we did today, but this is was a 15 minutes class. We have a full day of class and training the markings on the patients. So this is quite important in order, you know, to get the, the right position of the markings. Then we have two days of surgeries where Dr. Saldana and the surgeons will complete a full body contour with lipodefinition of the abdomen and, and abdominoplasty. Then I have two females, which are good candidates for lipodefinition and body contour. And then the next day, the last day, Sunday, we might have the training with a male patient where we not only do the, the, the scooping, but we also do fat transfer to the muscles. These are feet patients. So we get them bigger pecs, bigger deltoids, biceps, triceps, and these have to come really good for those surgeons. We have already trained 20 groups of eight surgeon, each one. And, you know, they have changed their practice with it. And we're quite happy of having any of you coming down to Sao Paulo, which we do trainings in English, Portuguese, and Spanish. Thank you for that information. And, and it looks like both your presentations were very well received and stimulated some great discussion, which brings us to the top of the hour and the end of the session. So I would like to thank my international friends and experts of uncomparable talent in Brazil, Dr. Ventura and Dr. Saldanha for, for participating today and spreading their wealth of information to the folks on this webinar. And again, anyone who's enjoyed this can look on the PS, ASPS EdNet for, for the videos and this discussion that was recorded today. So again, my dear friends, thank you so very much to the participants. Thank you for making, helping to make this a success. And we look forward to hopefully seeing you at PSTM in Boston, where you can meet all your admirers in person. Thank you all. Thank you, Dr. Robert. All right. Thank you all. Thank you. Bye-bye.

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