Hello everyone, welcome to American Society of Plastic Surgeons Global Partners webinar series. This is a great opportunity we have to be partners of this series, and today we are organizing a webinar with the title Blading Old and New, 62 Years in Plastic Surgery in Romania. Of course after presentation we have a session of questions and answers, so please submit your questions through chat feature, we will answer all your questions at the end of the webinar, and we also remark that the webinar will be recorded and it will be posted by ASPS AdNet probably next week. Our guests are very important plastic surgeons in Romania, and I have here three of the most important actually, Professor Alexandru Georgescu from Iuliu Hatzeganu University of Medicine and Pharmacy, Cluj-Napoca, will be our first speaker, he is also the future president of Romanian Association of Plastic Surgeons, Professor Mircea Ernescu from Carol Davila University from Bucharest, who is also past president of the Romanian Association of Plastic Surgeons, and of course our executive president, associate professor Cristian Radu-Jecan, also from Carol Davila University of Medicine and Pharmacy, Bucharest. Many thanks again for our partners from ASPS, and I think we can start now with the first speaker, Professor Alexandru Georgescu. He will present us Microsurgical Reconstruction of the Upper Limb Experience in Cluj-Napoca and in Romania. Thank you very much, Professor. Thank you very much, Zorin. So good morning, good evening everyone. Thank you for joining us for this event, I hope it will be a successful one. I am very honored to talk in this webinar and I want to thank a lot to the ASPS friends, all of them, for this opportunity for our society and for me personally. So I am coming from Cluj-Napoca, it is this part of Romania, which is called Transylvania. This part of the country is very well known because of this beautiful castle and of course maybe more because of the Dracula legend. I am working in Iuliu Hateganu University of Medicine from Cluj-Napoca, in Romania, and in the same time in the hospital of rehabilitation from the same city. So it is the opportunity to talk a little bit about this year, 1958, which is the year which marked the history of plastic surgery in Romania and this was first of all due to our first professor in plastic surgery, Professor Radu Pajonescu, which practically founded the society in Romania. Of course, and because I will talk about a topic in microsurgery, I have to mention here some of the pioneers in microsurgery in Romania, as you can see here. And also during the last 30 years, I think, our societies of plastic surgery, our societies of microsurgery and health surgery, promoted a good, a very nice partnership with a lot of well-known microsurgery surgeons all over the world, and part of them being also members of the ASPS, as you can see here, Riso Okoshima, Geoffrey Hallock, Fu-Chan Wei, Mardini, and other people well-known all over the world. Now let's talk about the subject of my talk. So, in most of these complex injuries, these kinds of injuries as you can see here, in which amputation was the only viable option, the limb salvage can be achieved successfully nowadays as you can see in these pictures here, with good morphological and functional recovery of this kind of lesion. Of course, upper limb complex microsurgical reconstruction is addressed to a lot of problems, but maybe I will talk today about trauma, peripheral nerves, partial-complex amputation, and simple or complex tissue defects. Of course, there are also some cases of congenital malformation, tumour, septic complications, which benefit in the same time for upper limb complex microsurgical reconstruction. So the microsurgical repair of the peripheral nerves is one very important part of microsurgery. As you can see here, for example, in this spaghetti, this lesion, okay, in which it's very easy by microsurgical techniques to obtain an M5 functional result, for example, with very good morphological and functional rehabilitation of the hand. But also the amputations represent another very important part of microsurgery and plastic microsurgery especially, because through this kind of procedure, replantation or revascularization, we can replant fingers, de-gloved fingers, or sometimes also more proximal lesions, as in this case, with bilateral amputation of both hands, as you can see here, and in which by doing microsurgical procedures, for sure, it's possible to replant all the right hand and a part of the left hand, but of course with good functional results. We are talking about hands and we have to understand from the beginning that the hand is very important, especially from a functional point of view, not only from a morphological from an aesthetic point of view. The functionality of the hand is more important for all the body. So if we are talking now about management of upper limb trauma cases with soft tissue defects, these are lesions more worse than simple lesions affecting just nerves or vessels or something like that. So when we have also a tissue defect, as you can see in this picture, the lesion becomes more and more demanding. How to approach? So we have to do a very complex approach because we are talking about hands. So here we have a lot of functional elements which should be preserved to be optimal for a functional reconstruction. So it's an anatomical complexity of the hand and also we need to restore the function. The main steps of this kind of procedures are represented by three main points. Assessment of the lesion, very early and careful debridement, as soon as possible defect reconstruction by using customized flaps. What about assessment of the defects? By carefully identification of the mechanism, it's very important the mechanism to know it's a crash injury, it's a simple cut injury or something more demanding. Time elapsed from the injury, pre-existing chronic diseases, location, extent and complexity of the tissue defects, establishing the functional balance, weighing of potential risks and benefits. For sure, sometimes we have to do an amputation. In these kinds of cases we have nothing else to do. Here it's a neglected case after electrocution, arrived in our service for example three days after the injury and you see what happened, what we found intraoperatively. So we have nothing to do with this kind of lesion because we have to preserve the life of the patient. So we have to do an amputation. For sure, our attempt is to preserve at least a small stump here of enough length to be able to receive a prosthesis furthermore. So also by microsurgical procedure we can obtain this result. What about debridement? Debridement is very important because we have to achieve the preservation of lasting function, at least a normal function as much as possible for a good functionality of the hand. So the debridement should be enough aggressive, sometimes in an oncological manner, but by paying attention to the preservation of as much as possible from the functional anatomical elements. Sometimes we need to associate our debridement with decompression incision and fasciotomy or sometimes fasciotomy to prevent the compartment syndrome and to improve the vascular supply of the distal segment. So you see here another demanding injury, it's a hot-calendar injury, also a neglected one, arrived late in our service, in which you have to do a very nice, a very careful debridement to excise everything from here and after that, for sure, you will be able to use, for example, a free flap, an interlateral type perforated flap to close everything. It's not possible to do in one step, you have to postpone the intervention, the reconstructive intervention for two, three days to obtain this result. What about timing of reconstruction? So you see here a lot of names, okay? The history of talking about timing started in 1986 when Godinat talked about early free flaps in this kind of reconstruction. All of us, we agree today, nowadays, that the earlier the reconstruction, the better the functional result. Sometimes it's better to do an all-in-one reconstruction as we are doing in cases of replantations, okay? Because in a replantation, you are obliged to do all-in-one reconstruction to be able to obtain a good result. Why not to do the same thing in another kind of complex trauma? Let's see this example here. It's a crush injury in a four-year-old boy with thumb amputation, fourth finger, complete destruction, should be amputated, forearm and soft tissue defects here, with rupture of the cubital vascular nerves pedicle. So it's a very complex injury in a very young people. What to do? Can we do, can we save this extremity? Can we give a hand for the further evolution of this child? For sure, we have to do everything for this. By using, for example, a complex reconstruction procedure, an emergency all-in-one reconstruction by using two flaps in a piggyback manner, by using one of the flaps as a flow-through flap, it's a fasciocutaneous axial flow-through flap. We cover the defect here by using this flap and we revascularize to the vessel of this flap a big toe triacet to reconstruct the thumb, because it's an essential thing in the hand. So you see the functional result, a good morphological one, but especially it's more important to obtain this kind of nice functional result. Sometimes in this kind of neglected crash injury, it's not possible to do the all-in-one reconstruction because it's an infected trauma, so it's a postponed one, it's a neglected one. You have, first of all, to debride everything and just after one or two or three days, after hearing very actively the wounds after surgery, you can achieve a good closure of the defect. How to reconstruct here? Because it's a very complex injury involving the tendons. For sure, by using, for example, two or three strips of vascularized fascia latae included in a lateral type 3 perforated flap, you can achieve a nice morphological and factual reconstruction of this hand. Sometimes it's the same, another case, demanding case, it's also a hot calendar crash injury of the forearm and hand, in which you have to wait a little bit, you have to debride, you have to do more debridement, one, two, three more days, and after that you can see that it's not possible to preserve the muscles here in the forearm because they are distracted, so you have to excise everything, you have to preserve just the vessels and the nerves, and you have to reconstruct the functionality of the hand by using, for example, a functioning muscle transfer, as the grass series muscle transfer, to obtain a nearly good functional rehabilitation of the hand. What about reconstruction? It depends on the type of the defect, complexity of the lesion, and what is very important, we can use a lot of flaps, a variety of flaps, starting from local to free flaps, which will be better. Let's see. So, for sure, local flaps are only possible to be used in small defects. As you can see here, it's a defect over the dorsal aspect of the index finger, so by using this nice flap, it's a local regional flap, in fact, based on perforators from the distal web space vessels, you can propel this flap for 180 degrees to cover the defect and to obtain a good functionality of your reconstructive finger. Regional flaps are rarely possible in complex injuries because, in very complex injuries, because of the extent and location of the injury, which can be very close to the donor site, and it adds also a donor site very close to this injured area. However, sometimes, in very well-selected cases, propeller-perforator flaps can be used successfully in these kinds of complex injuries. There are some advantages of using these kinds of propeller flaps. Because of the procedure, much easier than a free flap, less time consuming, replacing life with life, sparing the source arteries, allowing the beginning of the very early kinetotherapy. What is important, this is a microsurgical procedure, for sure, but it's not a microvascular flap. This has a very nice advantage over the kinetotherapeutic process because, having not microsurgical sutures, we can start the movement, the kinetotherapy for the hand, immediately after surgery. This is a huge advantage in obtaining a very good and early good result. As you can see, in this case, it's practically an amputation in which we did the replantation and after that we found a nice perforator from the cubital artery, one centimeter proximal to our suture in the cubital artery. And you see how nice you can obtain a good movement of the reconstructed hand. There are some criticisms, of course, over this kind of propeller perforator flap, because it's considered that it's a very close location of the perforator pedicle to the zone of injury. In my experience, I think that the perforator can be sometimes far enough to not interfere with the viability of the flap. You see here, in this case, with this kind of defect over the hypotenuse, you can find a nice perforator from the cubital artery in the distal part of the forearm. So you can use this flap to rotate for 180 degrees to cover the defect without any problem. And it's only a small donor site mobility here. On another case, in more complex injuries, it's a very demanding case here, with a deglobing injury of the thumb, index finger, all the hand dorsally and volarly, and part of the forearm. Even in this kind of cases, if you are doing a very careful dissection, you can find a nice perforator which supplies the partially deglobed skin of the forearm and you can use it as a flap. As you can see here, this flap, you rotate, you wrap around to cover the thumb, and you obtain this nice functional result, because the preferential function of the hand is preserved. Another criticism of this kind of method is the donor site mobility, because sometimes in bigger flaps, you have to cover the donor site by using a free-split skin graft. But by using, for example, in some well-selected cases, the pre-expansion before doing the flap. So you place one expander under the skin which will represent the flap, you expand it, and after that you will have the possibility to have extra skin to both cover the first defect, but also, of course, to close directly by direct suture your donor site without any free-split skin graft. Free flaps represent for sure the best option. The indication is depending on the complexity of the lesion and what about we are expecting to obtain for different cases. Because you see, we can have different scenarios. If we have to cover just the skin, a skin defect, as in this case, it's another post-electrocution defect, which involves the dorsal aspect of the hand, circularly the distal part of the forearm. So we need a huge flap, a very long one, which will be able to wrap around all the lesions. And by using an anterolateral tie, a perforated flap, we can obtain a nice result for this patient. If we have to do, at the same time, a revascularization, for example, if we have not only a skin defect as in this amputation here, but we also are missing some vascular elements, artery, radio-artery, or cubital artery, we have to replace it by using the same flow-through flap as previously, a flow-through flap, an axial fasciocutaneous flap, which will cover the defect and will be revascularized in the same time, the distal amputated segment. Another case, it's a suicidal attempt, a young female, which injected something here with skin necrosis, but also thrombosis of the cumeral artery. So in this case, we have to excise everything from here, the skin necrosis, and also the thrombus part of the artery, because it was damaged, and after that, to replace by using the same flow-through flap to cover the defect and to revascularize the distal devascularized segment. If we need a more complex reconstruction, including also needs to reconstruct the function by missing, because in this case, are missing also some tendons, not only vessels. So we have an amputation, we have a huge defect, as you can see here, so we need to reconstruct the vessel, we need to reconstruct the skin, we need to reconstruct the tendons. So here, we can use the same flap, a fasciocutaneous flap, as a flow-through flap, but including also some vascularized tendons, and you're still in these kinds of cases can obtain nice, favorable morphological result. More complex lesion, including this time also bones as in this amputation here in the middle arm with this kind of huge bone defect. It's a seven, eight centimeter humeral shaft defect with skin defect and amputation. So in this case, after doing the replantation, the revascularization of the distant segment, we can use a compost flap, a very complex flap, including ceratus anterior, latissimus dorsi, and the piece of rib, vascularized rib to reconstruct all the defect in one step. If you see here, immediate result, and 18 months postoperatively with a very good consolidation of the humeral shaft and also starting of the rehabilitation of the functionality of the hand. Also another case with complete destruction of the dorsal aspect of the hand with fracture, fractures and bone defects of all metacarpal bones and also some carpal bones in which we have to reconstruct everything in one step by using the same ceratus anterior flap together with two rib segments, vascularized segments, we can reconstruct everything to obtain these nice aspects from a morphological and radiological point of view, but especially more important, a very nice functional rehabilitation of the hand. Another similar case only with a necrosis of the first metacarpal bone and the huge skin defect in which the same flap with a rib vascularized segment can replace the missing metacarpal, first metacarpal bone with this nice three years postoperative functional result. If we have missing amputated fingers, this is maybe the more complex possible intervention from our point of view, because in those cases, you have to reconstruct the thumb especially or other fingers when they are missing all. So probably the two transfer should be the choice in these kinds of lesions. Of course, we can think about transplantation or something else, but for sure, these kinds of interventions are much better for the patient. Let's see some cases. Here, you see it's another very demanding lesion with amputation of the thumb, of the index finger, of the fifth digital ray with a huge defect over the palmar, dorsal and cubital part of the hand here, and with the vascularization of the remaining fingers. What to do? It's possible to use also a flow-through flap method, a piggyback method, okay, by using two flaps, one flap to cover the defect here, okay, as a flow-through flap, through which we revascularize a big toe truss to reconstruct the thumb. And you see the morphological and functional appearance of this very damaged hand. Or sometimes we have these kinds of lesions in which we have to reconstruct the tripodal pinch of the hand, so we need at least two fingers in front of the thumb to have a good functionality of the hand. In this case, we can use the anterolateral type flap as a flow-through flap to cover the defect, and we can revascularize a digital block transfer, okay, through the pedicle of this flap, okay, to obtain a tripodal hand with a nice functionality after that. It's not a very aesthetic, oh, sorry. It's not a very aesthetic, sorry. Okay, it's not a very aesthetic one, but it's a very functional one, this is more important. So in summary, I think the ultimate goal in the reconstruction of these kinds of complex injuries of the upper limb and of the hand especially is to obtain both a stable coverage and as soon as possible and as complex as possible functional outcome. The radical surgical debridement, the choice of the right moment for reconstruction, of the right method of reconstruction are of paramount importance in obtaining a good functional outcome. The primary all-in-one orthoplastic approach represents probably the key and the procedure standard in obtaining very good results. Thank you very much again to our ASPS friends and for inviting me, the invitation is honoring me and I was very happy to be part of this webinar. Thank you very much. Thank you very much, Professor Giorgescu to share with us your excellent experience in microsurgical reconstruction of the upper limb. And just before going on, I want to remind everybody to submit questions via chat and I promise you every question will be answered. And now we'll change our topic. We'll ask, I'll ask Associate Professor Christian Radujecan to continue with the next important topic in plastic surgery, breast reconstruction, a changing paradigm over 20 years. Please, Professor. Thank you very much, Zorin. I will switch now. I think that you all can see my screen. Yes, we can, Doctor. Yes, okay. Thank you very much. Hello, everyone. Thank you for having me along with the ASPS Global Partnership webinar series. As Professor Crencianu said, please submit your question. They will be discussed at the end of the meeting. And I will begin with the presented topic, breast reconstruction, a changing paradigm over 20 years. I work in the hospital where the first plastic surgery hospital was founded in Romania. Now we have two locations that they are shown here and the Carole University of Medicine and Pharmacy located also in Bupara. So this is Professor Agripa Ionescu. He has founded the Clinic of Plastic Surgery within our hospital. Basically, this is the place where all the departments and clinics of plastic surgery from Romania have started. And two years ago, the Presidency of Romania has awarded our hospital with a decoration in merit for the 60 year of plastic surgery in Romania. Also like in United States, breast reconstruction cases are increasing every year. But as you have shown in this article, I think that is mainly because of bilateral reconstruction, the skin conserving mastectomies, and not mainly because of the increase in autologous reconstruction. This is the numbers that I have got from Romania. We have roughly 7,000 cases per year, which stands for the second cause of mortality from cancer in women in Romania. And unfortunately, 80% of the patients are diagnosed in advanced stages, which bring us to a 36% mortality, which compared to Europe, about 29%, and the worldwide average, 31%. It's not very good for our country. Regarding the breast reconstruction, from the 7,000 cases, around 800, maybe optimistically 1,000 cases per year benefit from breast reconstruction, which gave us something about 15% of the total. And I believe that the causes are the lack of appropriate information, lack of acceptance from the patients, a lack of national general practitioner reference network, and lack of acceptance from our colleague, oncologists and radiation therapists. I know that in United States, it's reaching almost 50% of the total cases, number of breast cancer. But in Italy, for example, we have 25%. So we still have a long way to go. I think that we can divide the development of breast reconstruction in Romania in a few periods. Before 1990s, the early years, the development and implementation of wider centers, a very important step was the implementation of a breast national reconstruction program from the National Health System Care, the present times and the future developments. Before the 90s, there was only one national specialty hospital with a small number of departments across Romania. We didn't have implants, we didn't have a good literature experience and sharing of that knowledge. So the term reconstruction was reserved mainly for extensive cancer, like in this case, it's after 2000, but still I have used it for exemplification. And it reminds me from the original Latissimus Dorsi case published by Professor Pansini. This is a picture of, you can see myself there and a lot of my mentors and friends some 25 years ago. The early years after the 1990s began with the availability of the implants and expanders at the beginning manufactured ones from the Eastern part of the Europe and later on from established manufacturers. The development, further development of the microsurgery concept, new information about the available methods and the early pioneers in Bucharest includes Napoca, Ignasi and Timișoara, who have started to perform breast reconstruction. My journey with the breast reconstruction began in the year 2001 with the program financed by the Romanian Academy of Medical Sciences, which was designed to prove the efficacy and the benefits for this surgical procedure for our patients. We have published our results in the form of pictorial in trying to convince the women and the colleagues for the utility of this operation. We have, I have been part of the, one of the first microsurgical reconstruction in Romania in 2002 along with my colleague and friend, Dr. Stengel. We performed the formal term muscular flap and we have a good result. And later on from 2014, we have this program for breast reconstruction after oncological condition that is covered by the state. I am talking about the implants expander or implant expander variant. It was implemented by Professor Dr. Lasker, this is a mistake, it's only 3,100 Euro, which stands for around $800. The targeted patients were 800 patients per year, but the real execution is around half. And we have 19 location in Romania that are involved in this program. The surgical intervention is covered up by the National Health System and the breast symmetry surgery was recently recognized as part of the global treatment for breast reconstruction in August, 2020. We have also like everywhere else, the implant based methods, direct implant or expander implant, the autologous with the gold standard with the abdominal based tissue, but also alternate flaps. We have mixed like the latissimus dorsi reconstruction and adjuvant procedures as listed here. I do believe that in the case of breast cancer or high genetic risk, we have to put in order a tumor board to give us the indication regarding the mastectomy, the partial excision of the tumor, the oncoplastic techniques or variants of skin sparing, nipple sparing technique with or without radio, chemo and hormonal therapy before or after the surgical treatment. And also the breast reconstruction, which can be immediate or delayed with several methods. What I have put in practice, it's the abdominal CT angiography after the Houston Methodist Hospital protocol and the evaluation with the Doppler before the autologous reconstruction. We are using also the 3D reconstruction and simulation, either with the software or cellular phone based programs to evaluate the dimension and the volume of the gland. We have introduced in practice also the venous coupler without a Doppler signal, as you can see in this picture, but it's very helpful in reducing the time and increasing the efficiency of our anastomosis. We are trying to implement the endosomal green monitoring, the double pedicle DEIP, the 3D printing of perforated system to establish a formal program of training in oncoplastic techniques to introduce the alternate free flaps to solve the lymphedema to sensitize the deep flap and also to engage in immediate reconstruction with radiotherapy. These are the numbers for my last six years. You can see that early on, the LD was the working course, but in the last two or three years, we have shifted to implant based reconstruction. We have performed some analysis regarding the breast reconstruction, as you can see here, regarding the days of hospitalization and the implant is the lower numbers. We have divided it between the unilateral and bilateral cases regarding the reconstruction method and also regarding to the stage of breast cancer. And we can see some connection between the chosen method of reconstruction. Regarding the radiotherapy, also we have performed our analysis and here are the costs that are calculated only with direct costs without the salary and the amortization of the techniques. And you can see that expanded to implant is very costly, the most expensive one. And paradoxically, the deep flap is not so expensive, at least in our country. Here are a few of the cases we have implemented the synthetic meshes, like in these cases that allow us to stabilize the interior pole of the reconstruction. We have used synthetic meshes and something that I like a lot, especially in big breasts, to use the lower dermal flap of the excise place of the mastectomy as a support instead of synthetic meshes. We have introduced last year, because they were imported for the first time in Romania, officially, the acellular dermal matrices that allow us to achieve good results in this case where you can see, also at the beginning, the breast was pretty much up on the thorax, but it later on descended and we have achieved a very good symmetry. Another case is with the acellular dermal matrix. We have also used lately in support of our direct to implant reconstruction, this type of advancement flap from the abdomen, which allow us to shortcut the need for an expander. Another case where bilateral reconstruction, it was a revision of the left breast reconstruction and also a reconstruction direct to implant with abdominal flap. And another case, which had the inferior sector for a breast cancer and an indication for skin and nipple spurring mastectomy. We use also adjuvant techniques, like the lipofilling, that allow us to control the minor defects after breast reconstruction. Like in this case, we use combined methods, like latissimus dorsi on one side and synthetic meshes on the other side. And you can see the result, we can get good result. This is an exemplification of the technique that I have mentioned before, with the conservation of dermal lower pole pedicle, which allowed us to get fair results also in this type of big breast and the ptotic ones. We have also implemented the DEIP flap in our practice with a lot of intraoperative, intra-flap anastomosis, like in this case, and using the double pedicle from the internal mammary pedicle, like in these cases, with the predominance of the superficial system, where we have used the distal part of the internal mammary for the superficial system. I think that a very good oncological surgeon is paramount. You have to assemble a team that allow you to conserve good quality tissues in the mastectomy with some fat in the inferior caudron and conservation of the inframammary fold, and to avoid this kind of uneven and unstable regarding the vascularization flaps. Regarding the areola nipple reconstruction, this is our preferred method, but we also use banking cartilage and also nipple sharing and tattooing in selected cases. Regarding the inframammary fold reconstruction, I'm very attached to the technique described by Andy that allow us good results even in the absence of this fold. Of course, we had complications, some of epic proportion, like in this DEIP with the watershed vascularization. We have stasis even on latissimus dorsi flaps. We have exposure of the implant, or pretty much this case, which I think it was the most difficult to resolve complication, because first I have used a latissimus dorsi, which failed, partially failed, and I have to resort to a epigastric perforator flap and also after symmetrization, I could solve it somehow. She denied further refinements of the techniques. And some cases refer from colleagues, mainly for misguided indication or maybe due to the characteristic of the patients. I want to mention that I have benefited a lot from my one and a half months in Houston, invited by Professor David Matcher. I was visiting Andy Anderson, a Houston Methodist and Debatee VA Hospital. Thank you to Lynn Jeffers, to Greg Evans and Robert Murphy for agreeing to sign the memorandum of understanding between our society. Thank you also Romina for helping me. And in the end, I believe that breast reconstruction depends on very multiple characteristic, but in the end, it's about local resources and money, patient personal preference and expectation, and not the last surgeon experience and goals. Breast reconstruction is very important and necessary step to achieve a good quality of life in women who have suffered from mastectomy or partial mastectomy. And even so Romania has a national health program, only 15 to 20% of the women underwent this procedure. I think that we can benefit from the partnership to gain expertise, to implement some registries regarding the implants, the reconstruction, the BALCL and Fabi Grasti, to open research opportunities for our younger colleagues, to improve the training for residents and to also access the at night resources from ASPS. Thank you very much for your attention. It was a wonderful meeting. Thank you. Thank you, Professor Zekan. Very nice and complete presentation. And now we'll go on. First of all, I want to remind you about questions that you can send us and our presenters by via chat. And now we'll continue inviting Professor Dan Mircea Ionescu to present his great experience in pediatric plastic surgery, the history, challenges and future trends. I think you have to unmute your mic your microphone is closed Professor Enescu, can you hear me, please? We cannot hear you because your mic is closed. I think play button over the control bar yes I think it's okay yes but just push the play button here okay good great good evening for our colleague in the United States and Romania and to present you the specific challenge for our country and for everyone in the in the world it's a pediatric plastic surgery in Romania history challenges and future trends and it's we we talk about being in our care unique special defined not smaller adult and the childhood psychological and development feature that not be sure to be overloaded and this is this feeling about the new children he it's in our world that must do something for her for him to to grow on them to be perfect it's possible to disturb his his life and our work and to change the life of his newborn and we work in the specific material he sees 100% water and the 100% anabolism and what is most important must work quickly because it's this instrument most important he give the universe the brain must be negotiate quickly don't do a little little mistake on the surface on the brain because it's very important for all the life order on all the move of us it's very important for all the life of this newborn and today's newborn it's it's a quick second when this change and become an adult and this adult it's become a person he work in this collectivity it's a person he must be important and don't forget every child come to the world with this message not yet disappointed with people if Tagore he say you can give a child it's the chance for the world to do something important with him and the last century give us a lot of important advancing the genetic material into or the the science and what is important is must connect it or the science to change to use and to change the life he must be very strong in the in point of view social for for this children and I want to present you the last children of plastic surgery in our country it's a plastic surgery for children it's born in 1988 the bigger exam this hospital is my place in the other can disease hospital 32 years ago and in 1988 was one surgeon five nurses 28 beds 600 burns per year 90 average 90 fatalities each year no books about pediatric plastic surgery no books not any knowledge and think to be in five rooms in the old hospital and with 90 fatalities each year and this disaster and that must fight a lot it so to fight with all the society to understand the much must understand it's important to change something and to to give a chance of this the children today this is our center it's burn intensive care and the unit in plastic surgery and the world and the 48 beds the team is 10 plastic surgeon very important young and very determinate and for residents to an astrologist 40 nurses 30 nurses it's a foundation of the treatment inverse anyone knows is psychological social worker and the rehabilitation team and this is our department 42 years ago and this is my intensive care rooms think think is this is a room when the must do something to save the life of the child if 80% 90% 100% and my record must do to to can't do this and was a long way to temporarily to can change all these things and what happened I need instrument a strong instrument the changes this way he is in principle the disaster I build a new skin bank up first skin bank in our country in 1999 and this skin bank is only for our department but in short time in one year become the skin bank for all the country because we can give the skin for all the important hospital he treated births burns in or special cases with of skin in in our country and another very very important moment was the beginning of new building me and two two friends of mine very good and the construction and an architect we all together and with me become to build in the middle of the hospital this building is our conception our mind and I put inside what I think is the best for the disease kind of child he children he's very poor he's come in the law society he'd need a lot love and help to come back and days in collectivity and to be normal normal what it's possible if important of the world you can understand and what is most important for for this place the soul of this place is the team and is a team in 2005 when we we open this new building we have very determined determined team and look it's another is a surgical room this is our rooms we treated this kind of children with a lot of malformation and deformity and become in short time pediatric plastic surgery clinic in Bucharest it's a huge place to come all the pathology for children in the country 1,000 pediatric burns each year with general mortality less like one one percent and lau 15 it's 85 18 cleft lift and palate surgery each year 40 60 congenital hand malformations inductively polyductively amniotic band and all kind of malformation it is possible children because our centered find and gain this expertise to can't negotiate with this malformation as a congenital condition micro tear hemangiomas nevus pigmentaris 300 post-burn reconstructive surgery patients each year 300 other good trauma soft tissue complex on amputation syndrome and a lot of other trauma 2,000 our patient what means minor burns and trauma all this number is only number but means soul of children he it's only beginning because children can't have few day few months and they must control and to build to reshape and to be very careful with a 18 years until become adult and we find our care concept and burn or burn care concept and did not our because yes is generally can talk me you know it's or any book on the inverse shows this concept yes it's possible but we learn and we discover each point of this in our treatment each day and the back of this in the it's a 25,000 children with treated in the last 42 years when we become with this clinic in the plastic surgery for children and what is this early excision in deep and extensive burns skin bankness is 99 and his skin banking I talk about this it's most important with this way we change the future of the children and become don't die and give a chance and give a very good chance for for his day future efficient reanimation formula we understand the parkland it's not enough for us special for the children 0 5 it's important parkland or Galveston formula it's related surface related to not to this lost of liquid is not for the weight it's for the surface of the children preventive a good complication metabolic immunological nutrition support infection prevention local treatment early excision early excision it's very important because for us we become to do early excision from first is possible first hour he come in hospital and can take off 20 25 40 percent burnout efficient general treatment we was very important because must discover but invite my must understand and it's only of not this generally from general principle but especially for the possibility of our country and with drugs here we can use in our country psychological and social support we have subsology psychological social support we use early rehabilitation from first hour of they come in the hospital we become psychology of early rehabilitation post-born reconstruction and team approach what is most important the friendship and the psychology of the team he work all together not a number it's the same mind he work all together in same time and what it's the results the results it's this graphically for me it's a big big pleasure it's the dream of my my life and when coming this hospital in to us 85 fatalities one to 1,000 children he comes in hospital he burns and 85 die it's it's very very big drama for me personal because I am only one and die in my hands and in 2000 of the skin bank I first become a new building new facilities we look it's zero and six six hundred children he is present and come in our hospital and our fatality for 90 percent 70 percent 60 percent was zero he it's fantastic for all the center in this old what is our important interdisciplinary burn and plastic surgery concept is provide optimal acuity care for burn and trauma patient complex and the rotating team it's 20 hours for pediatric patient and his special needs the complex teamwork with the patient and his family from reanimation through reconstruction to rehabilitation to social reinsertion wide experience in burn trauma and reconstruction the team must be exposed to major moderate and minor case to maintain optimal training and motivation at least 300 burns per year and burns care requires special technical condition in the distinct area skin banking the unit must be a part of the large it is very important to be in the large hospital because it's most important accident can happen to the human body and needs all the specialties and it's very important to be in the complex hospital all the com specialty he he must work quickly in the same patient must solve the problem in the short time the team must be self-selected because it's not it's not a work he must do in any any condition must be with the pleasure only the personal doctor he loved to do he loved to do it's a it's fantastic to do the birth the children with the child of the birth it's can be can stay in the hospital and they do this this things and focus on the patients and his his dates and this is the patient he with rehabilitate and look it's amputate of the lower extremity and put in the prosthesis and go home walk and is very important when go home to be same like what come the way when they come in the hospital another part very important of our activity in this cliff lift and pallet in the our training becoming 99 1996 with right in this slide with international team of dr. Bill McGee he organized the five mission operations in our hospital 500 operation in five years it's a number he's must repeat all the time and after this we can't organize we was able to organize the first interdisciplinary meeting in 2000 in Bucharest it's a special training and I think in the country it's only one place it's possible to be in the hospital but it's only few places who has a team a complex team he must can can work in same time for one patient of this important malformation this treatment is complex long-term interdisciplinary situation like in births the final results require long years and hard work and good quality life you can see only after 18 years to do the births and cleavage and part for children means to have very very to be very patient it's not the results need not after five minutes after two three months it's after 18 years after when these children become adult and go on the society and can become member of the family to have a good family with children and can't work and have a job and it's very important to be normal and we don't work a lot to do homeless and another point very important our activity is the moment of Professor Kenneth Selyer was the president of the official malformation in the world in 1898 with his team David Jenikov Habre he all together training me in Dallas Medical City Hospital in Dallas and doctors is in Bucharest a few times and a lot of talking about his specialty and surgery he can help us to show us what's the best state of art to do crafty fan palette I want to show a few results but this is not a good because the real results it's when become adults not it's after one two hours after the surgery other pediatric plastic surgery condition is in front of him and Germans here deformities never speak mentalist handed foot congenital malformation and after this we want to be accredited accredited is must know what is our real level and we take the certificate of competition up by a Bopras Commission our accreditation I will present it in 2008 and for burns most important in the world I think is the accreditation of professor David Herndon and Galveston he talked about our hospital about our activity it's it's good and they can be on the Shriners Hospital anytime and this is a certificate for the integration and the present challenges is that present our team member practice only in public hospital not private practice activity we work for this and in few next year we I think we can't do this and what it's important it's important to become to reconstruct before one years of age old and we don't care for all the children he needs is because it's on the ground cleaning for all the country talk about this the resident are trained mainly for a constructive surgery very little for burns very very little for births and children or plastic surgery in children I think but formal training in aesthetic surgery this is the future because this center I show you it's not for forever this future is with money of mondial bank I with money of mondial bank in the to 2023 we finish a new building it's inside all the circuit is like a last generation of hospital in the order was the was the European country and in state sure and we have in same place burn I could burn plastic surgery intensive care no not no not ology and altogether in same time we can't work and to do the best and the best results with this work future project and needs a better national not a better national but the national infrastructure we don't have an infrastructure in this moment national infrastructure for pediatric plastic surgery national registered for our specific pathology I think is for all the pathology it's same not only for plastic surgery a complete team for every special condition like cleft lip and palate you know it's a lot of specialty he must work to all together in same time we we don't can this is moment this for birth hemangiomas infantile hemangiomas pathology of malformation vascular malformation we want to rebuild the protocol with neurosurgery I build a hospital for neurosurgeon in our hospital and we want to solve the important problem with the children with syndrome he needs neurosurgery and the plastic surgery in the same time one example integration of soft tissue engineering 3d 3d printing and other state-of-art biomedical technology in our current procting in conclusion pediatric plastic surgery it's very important to do today but must have in your mind the future because what we do and what to see in this moment on the in the little because when grown what we do today must be at the very big disaster after 10 years after 15 years I think left me from Pala must have a very good protocol because the result is perfect after surgery after five years but after 10 years is possible to be on the very big big malformation that it's very difficult to relate it and to connect it and negotiate with these results of future this is our challenge improve our pediatric anesthesiology because it's important to have an anesthetist he is specialist in the children and we want to be present with all the scientific advances for 21 century and in conclusion children is not smaller others who know this it's another texture another composition I talk about 100% 100% anabolism it's anything it's anything it's change is not like an adults children it's special special and must negotiate very very delicate with this condition and it's important to think all the time what it will be the results when to have 18 years old and we consider each case it's a static surgery for for me for my team is very important this concept we do all the time a static surgery for children with burns with free people up a lot palette with anything because it's a challenge of our life to do a generation next generation to be better because I think the new generation we build a new world thank you thank you very much professor in high school I'm always impressed about how you treat those delicate and special human beings the children and about the results you can obtain thank you everyone of course time is not enough to cover everything we want to say about these topics as far as I understand our host Laura Weber from SPS still can provide us some minutes for questions is it true Laura yes absolutely we have time for questions thank you so much so for professor George's school I'll start with the question asked by associate professor sorry Harriga from Bucharest he wants to know how many complex limb reconstructions are performed in your clinic each year accepting this year of course this year is a special year because there's a COVID pandemia and that's why we are meeting in this way so please professor Georgia school thank you for the question until five six years ago we treated more more patients because we have been we had the single Department of Plastic Surgery big Department of Plastic Surgery doing microsurgery in this part of the country but nowadays there are a lot of other services in which is possible to perform this kind of microsurgical procedures so until until let's say 2014 2015 we did about more more probably more 50 60 70 cases per year this kind of complex injuries of course not only hand surgery or upper limb surgery but also for lower limb and another kind of lesions nowadays we are doing less because our hospital is not working in this moment as an emergency hospital it's working just a rehabilitation hospital so we treat still treat some complex injuries but not so many as as before thank you professor Georgia school there's another question for you also is from Klujnapolka from Dr. Jancuja he wants to know what are other alternatives for reconstructing metacarpal bone defects beside free rib transfer yeah of course fibula is a good indication but it's a little bit too big for metacarpal bones I think so I generally do not use fibula for metacarpal bone repair and iliac crease can be a good option but anyway I'm using generally the rib because can be part of a huge flap if you need to cover huge defects sometimes it's better to have a huge amount of tissue to be used together with with the bone itself so that's why I am using this kind of lesion and also because the muscle is able to feel the defects by using the fibula it's not so easy it's too big using the iliac crease is a more demanding procedure I think and sometimes with a lot of possible complications thank you so much for professor Jekan this question actually it's more request professor Hariga asks you to mention Romanian Association for of plastic surgeons efforts to include as many costs as possible in the expenses covered by health insurance in breast reconstruction can you please thank you very much I would like to say that our efforts that has gone to complete and develop the breast reconstruction program we had several addresses asking to cover also the materials like the meshes or the ATMs and the cost of symmetrization till now as I said in August 2020 we have the first success regarding the coverage of the symmetrization surgical intervention and we do hope that in due time maybe next year we can also expand it to the synthetic meshes and our cellular dermal metrics and it's a coordinated effort for from the Society the Ministry of Health Committee and also all the colleagues involved in breast reconstruction in Romania thank you so much there is also a question from Cluj-Napoca from dr. Biancioia for for you what were the indications for the abdominal advancement flap for breast reconstruction very good question indeed I have started to use this abdominal flap advancement for small breasts that is being a cup a or B and where the defect the mastectomy defect is no wider than four centimeters because you have to advance a double this width flap from the abdomen to surpass the missing tissue and this allow you to go directly to implant reconstruction avoiding the expansion stage of the reconstruction but again in small or maybe in moderate breast thank you very much I also ask you with the short answer which is your preference for breast reconstruction primary or secondary and why is that it depends it's very it's complicated it's complicated this is let's say I would like to say this but if your only tool is a hammer the whole world would look like a nail so I have started with two or three methods and I have looking to master them more or less but I would say that if the patient has the indication it's not an extremely obese got good abdomen tissue and she is willing to embark in the long time effort or a microsurgical reconstruction this is my preferred method the deep flap but if not if she's not willing and she's looking for a quick answer whenever I can I use implants and later this is my opinion that more and more women are opting for the more simple for the more simple solution even if the results are not so good in quality but they don't want to embark in more complex reconstructions thank you okay I see one question for professor in a school it comes from dr. Tonga from Zambia and he wants to know which is the resuscitation formula that you use for burn children we use formula keys related to surface and burn burn area and this 2,000 metal square metal square plus 2,000 or surface surface area thank you professor in a school and also from dr. Tonga there's a question for all presenters on the subject of teamwork he says I'm well acquainted with mental and emotional tool that working with limited resources can have on your team members working with burns or trauma how have you been able to address this can we start the answer with professor in a school to repeat please yes so dr. Tonga from Zambia yes I'm well acquainted with mental and emotional tool that working with limited resources can have on your team members working with burns or trauma how have you been able to address this no it's important we have the results we have anything we have good connection when we have a family we form a big family with the nurses with the all kind of person who work in our building we build new building keys you are beautiful and inside it's the last generation of instrument in the world and we have all the drugs and what is necessary in all over the world we did is any difference until our place and any place in this most important center in the world and this give a power and it's this team has 15 years old minimum and in 15 years it's a lot of it's a piece of life and this piece of life we build the strong connection that we work all together in same time love keep symphony orchestra thank you very much professor professor she can can you also comment on the teamwork the team that you lead Please unmute your microphone. I would say that I have overcome the shortcoming of material resources by patients, by involving the management in the hospital, and by optimizing the expenses in my cases. I would say that the most precious resources is the human resources, because you can overcome material or financial deficit, but it's very hard to set up a human team, a working team. Thank you very much. There is also a question from Dr. Avdeshir Vahidi. If the multidisciplinary approach was initiated in your department in case of breast cancer reconstruction, this by saying you have breast MDT meetings. Actually, even from the start that I move in this hospital, I have constant talks with the oncologist and the general surgeon regarding each breast reconstruction. We had the informal discussion, but in the last six months, we have formal meetings every week for the Oncological Therapeutic Committee or board, whatever you like to call it, regarding each oncological case in our hospital. We have also included images, the radiological person, and also radiotherapy physician. Each oncological cancer case is discussed before any therapeutic decision, excepting the basocellular and scomal cases of the skin. Thank you very much. Professor Giorgescu, can you please comment on the teamwork? I think that the human resources is the most important one, because it's very difficult sometimes to have enough people and to have especially dedicated people to understand the necessity to be there every time when the service is needing you. But anyway, based on my experience, I think every time we have been able to have a good team and to work not only with specialists, but also with a lot of very good residents. So, we have a very nice residential team which is working together with us and we can manage these kinds of things. I think it's not really a problem if the people understand, and this is the education part of our work as teachers, to educate our co-workers and especially the young ones, to understand the necessity to be there when we need them. Thank you very much, Professor Giorgescu. Unfortunately, we have to go to the end. Of course, discussions can proceed and probably will end late in the night. But we have to close. I have to remind you that this meeting, this webinar was recorded and you can also access it in the ASPS AdNet, if you are a member. Thank you very much, Laura, for hosting this meeting. Thank you, Professor Giorgescu, Professor Gekan and Professor Enescu for your presentations. See you in the next meeting on the Global ASPS Webinars. Thank you very much. Thank you very much. Thank you. See you soon.

plastic surgery

microsurgical reconstruction

breast reconstruction

pediatric plastic surgery

Romania

limb salvage

propeller flap techniques

autologous tissue

burn management

congenital anomalies

surgical expertise

teamwork