Okay, welcome everyone. Good morning to all our colleagues in the United States and good afternoon and good evening to all our colleagues who are in other global partner countries. It's a great privilege to be a part of this webinar series with our global partners. While waiting for others to join in, I would like to introduce ourselves. This is Professor Suhan Ayhan. I'm the President of Turkish Society of Plastic Reconstructive and Aesthetic Surgeons and I'll be moderating this session this morning. Let me introduce you to our speakers. Our first speaker is going to be Professor Akın Yücel. He is a former faculty member in University of Istanbul in CERAHPAŞA Faculty of Medicine and he works as a private practitioner at the moment. He is the past president of Turkish Society of Plastic Reconstructive and Aesthetic Surgeons. Our second speaker is going to be Professor Selahattin Özmen. He is a faculty member in Koç University Hospital Department of Plastic Surgery and he is currently the vice president of the Turkish Society of Plastic Reconstructive and Aesthetic Surgeons. Today we are going to cover a breast augmentation topic and Dr. Yücel and Dr. Özmen are going to discuss decision making and the complication management in breast augmentation. We'll be happy to take questions after their presentations so please feel free to use the chat screen for your questions and I'll be happy to forward their questions to the speakers at the end of the session. So I believe there are people joining in and I would like to invite Professor Akın Yücel for his lecture. Dr. Yücel. Thank you. Thank you. Hello. Good afternoon to everybody. First I would like to thank the American Society for the kind invitation. I have nothing to disclose. Breast augmentation seems to be an easy operation with high satisfaction rates but in reality it's a complex procedure with very high complication rates. Accurate preoperative planning is mandatory for a successful result. There are too many parameters both in implant selection and technique selection. We will talk about silicone implants so the discussion will be about the shape and volume of the implant and also which tissue plane, the new site of inflammatory fault, incision choices, fat injections and asymmetries. In implant shape we have to answer the question if we want to use a round or unautomated implants. Round implants, the advantages of them are implant selection is easier, easier implantation, needs shorter incisions. There are smooth surface options in times of ALCL. There are less rotation risk, softer and gives better upper pole fullness. However, these advantages are augmentation. It makes augmentation rather than reshaping, gives more round appearance as they are low cohesive, less resistant to capsular contracture and higher risk of rippling and less implant alternatives. However, anatomical implants makes both augmentation and shaping, gives more natural view, causes less rippling and more resistant to capsular formation and with swing effect it corrects pitosis more effectively and there are more implant alternatives. However, implantation, implant selection and implantation is more difficult, needs longer incisions, no smooth surface options. There is high rotation risk and the edges are harder and can be palpable. Best indications for anatomical implants are patients with tight constricted lower pole with poor defined inframammary folds. Form-stable anatomical implants expands the lower pole constantly. Round implants do not make this expansion and the lower pole usually stays depressed even after 13 years such as in this patient, but subfacial anatomical implants makes better definition of the lower pole. Especially in skinny patients with tight lower pole, dual plane technique should be preferred with anatomical implants. Also, in all augmentations with subfacial plane, in subfacial plane, anatomical implants should be preferred because they give a more natural view, less rippling and less capsular contracture. Best indications for round implants are patients with insufficient upper pole fullness with well defined lower pole without glanular pitosis. Tissue quality at the lower pole should be enough to support the implant, otherwise there will be glanular pitosis. All round implants, I believe that should be used in dual plane technique. And this is another patient nine years later. And also in augmentation mastopexy, we prefer round implants because it gives more definition to the upper pole. This is an example with round implants, dual plane augmentation mastopexy, another dual plane round implant. If the brace is completely reshaped over the implant, which is called a reduction augmentation procedure, anatomical implants can be preferred in mastopexy also, such as in this patient and this patient, it gives more natural view to the upper pole. In fat patients with empty upper pole, you can use either round or anatomical, it will not change a lot, even insufficiently. The other question is implant volume. There are three parameters, width, height, and projection of the implant, but the volume is essential for the patient. So we need to understand the desires of the patient preoperatively. These charts are valuable and there are some simulation systems like 3D imaging systems, or you can make simulation with external implants. Many companies have these implants and you can insert them into the breast and wear a t-shirt and tries to understand the final shape of the breast. This usually gives a correct simulation such as in this patient postoperative view, which is very similar such as in this patient also. But the most important parameter is the implant width, because it is restricted by the chest wall anatomy and should not be wider than the ideal breast width. These calculations are not very complex, you need to subtract the tissue thickness from the base of the hemichest wall. A common mistake is trying to match the implant base diameter, implant base diameter to existing breast diameter. This will not improve the appearance and will cause unsatisfactory results. Such as in this patient in the bottom, you can see the small implant didn't give a good view and we changed it to a larger implant. Implants should be chosen according to ideal breast footprint, not the actual breast footprint. Also in patients with loose tissue, smaller implants will not give satisfactory results. If the patients want a small implant, you need to tell them that you need a volume to fill the empty envelope, otherwise the result will not be satisfactory. The implant height is the other parameter. Medium height implants are used in majority of patients. Tall height implants can be preferred in patients with long thorax, low seated breast, but they need a long lower pole and not suitable for constricted lower pole patients. This is an example, low seated breast. And short height implants are very uncommon. They can be used in patients with a short footprint. And implant projection is the other parameter. And it allows to gain more or less volume with the same implant footprint. High projection implants provide small volume and projection with the same footprint. Very useful in deflated breast and with narrow chest wall. Moderate projections are suitable in majority of patients. However, low projection should be preferred to widen the footprint, especially in tubular breasts. An example. And also in small breast asymmetries, chest wall asymmetries, if the footprints are different, you can get the same volume with different footprints. Or in asymmetric breasts, you can have different volumes with the same footprint. It is not wise to use very different implants. If there are small asymmetries, you can make more symmetric by removing tissue from the bottom of the breast. The other issue is the technique selection. The position of the fold and the incision selection, tissue plane, surfacing or duart plane, and fat injections will be discussed. The incision, we'll talk about inframammary fold incisions. This is the most common one, especially for anatomical implants, and should be placed on the new side of the inframammary fold, lateral to the drop line of the nipple. It gives better control of fold, easy access to all cataracts, easier manipulation, especially in secondary surgery. Perioral incisions cause more biofilm formation and capsular contractions, so they are not recommended. Axillary incision, I think, is only for inflatable implants. Determination of new position of fold is the most important step of this surgery. Distance between nipple and fold should be long enough to get the implant in. In majority of patients, that distance is short and should be extended. Larger the implant, you need to lower the inframammary fold. The nipple inframammary fold distance, if it is longer, it should either be filled with larger implants or should be shortened by a mastopexy procedure. In breast augmentation, if inframammary fold is not lowered efficiently, implant will locate too high. This will result in a full upper pole and empty lower pole with downward orientation of nipple axis and pitotic view. Breasts will look like puberty breasts. If inframammary fold is lowered too much, this will cause downward migration of implant and will cause bottoming out, empty upper pole and stargazing nipples. Breasts will gain an older appearance. In patients with high seated breasts, tight skin and muscle, trying to use large implants may result in inferior migration of implant and inframammary fold by the pressure of the muscle. In tubular breasts, all dimensions of the footprint is narrow and lower pole is constricted. Footprints should be widened in all dimensions. Lower pole should be expanded and inframammary fold should be lowered. Correct location of inframammary fold is important for a natural view. This is subfacial augmentation. Bra marks are helpful to determine the new inframammary fold like in this patient. Especially in tubular breast patients, it is very difficult to calculate the accurate site so bra marks are useful. But more accurate way is choosing the site with LVC, lower ventral curvature. LVC is the distance between nipple and inframammary fold. In an anatomical implant, LVC is the distance from the midpoint to the inferior edge of the implant. Preoperatively, you need to touch the thickness, calculate the thickness of the implant and you need to add it one to three centimeters to the LVC of the implant. And you need to mark it by stretching the lower pole. Also, companies give charts and LVCs for each implant. Upper and medial breast borders are the most visible borders and should be symmetrical. This is especially important in breast augmentation. In case of nipple asymmetries, the reference point should not be the nipples. The aim should be getting a symmetric upper pole and cleavage. Markings should be done in upright position. The new site of the inframammary fold should be marked by stretching the lower pole of the breast. Inframammary folds should be symmetrical and incision should be lateral to the drop line of the nipple. In case of asymmetry, primary concern should be symmetry of the inframammary fold rather than the nipples. Symmetric upper borders can be achieved only by creating symmetric inframammary fold levels. If new side of fold is marked according to nipples, asymmetry will be exaggerated. Nipple asymmetries are more acceptable than asymmetric upper and medial poles. In patients with acute inframammary fold angle, smaller or short height implants should be preserved instead of trying to lower the inframammary fold. In that type of patients, trying to lower the fold may result in double bubble deformities such as in this patient. Inframammary fold is not a well-defined anatomical structure. It is formed by crisscrossing dense fibers secure the dermis to the deep fascia. Scar fascia divides the subcutaneous fat into two layers. Superficial fat is more dense and thicker. Deep layer is thinner and more areolar. Superficial fat supports the inframammary fold. If scar fascia is divided during subglandular augmentation, the loose and areolar subscarpa space becomes load-bearing area for the implant. Over time, this space opens up under the force of the implant, resulting in inferior implant migration and scars rise up onto the breast. Inframammary fold should be secured to the deep fascia after breast surgery. If you can make the dissection first over the scar fascia and keep the dense fat tissue here, this will support the inframammary fold post-operatively and a good fixation point. The other question is which plane, submuscular or subglandular? Dual advantage of dual plane is less implant visibility at the upper fold. It hides minimal capsular contractures. In patients with thin subcutaneous tissue, it should be used. One advantage is implants always stay high and upper fold fullness is always protected, usually protected in dual plane augmentations. There are less risks for pitosis and downward migration of implant in the long term. However, it's an unnatural tissue plane, it's more painful and needs longer healing period. More important, there are more animation deformities and waterfall deformity in the long term. In patients doing active sports, it should be judged. This is view of a patient per-operatively. The upper view is submuscular and the lower view is subfacial augmentation. It's a round implant and you can see the upper border very easily. In markings for dual plane augmentation, we mark the level of nipples. Then we want patients to raise their hands over their head and mark again the level of nipples. These markings show us up to what level we will make the muscle dissection. The muscle should be dissected completely, not lower than the lower marking, but not higher than the upper marking. The fascia and muscles should be cut completely and up to this, the muscles should be weakened, only lateral resources should be weakened. For dual plane augmentation, first we make the markings again and then we check for the symmetry. Then we make the incision and we keep the fascia here, scarpus fascia, for better IV formation, fixation. In dual plane two or three, we need more subfacial, we make more subfacial dissection. However, this dual plane one patient, because there is no pitosis, then we find the lateral edge of the pectoralis muscle and we go under it. We make sharp dissection always. Then we start to cut the inferior border of the fascia. And then we cut also the medial attachments. There is an endoscopic view, it should be more useful. And you see we cut the muscle completely, both inferiorly and medially up to the level of our markings. We need to see the fat tissue, yellow fat tissue, when we cut the muscle. Otherwise, the lower fold doesn't expand and the IMF cannot be defined precisely. You can see we cut the muscle, this is the medial insertions. Also, we make lateral dissection, not too much. And then we dissect the superior lip and then we check our pocket. And lateral dissection, it should be done very limited. And then we dissect the area between pectoralis minor and major muscles. If we don't, this, sometimes patients have a fold at the level of below the axilla. And after this, we wash with triple antibiotic solution and we again check the pocket. Then we always use nipple shields. I always prefer to use a scissors and I dissect the pocket finally with scissors. If there is need for lateral expansion, we make more dissection, but not blunt dissection. If it is okay, we remove the implant, we remove the scissor. I always use drains. And before opening the pocket, we put again triple antibiotic solution. If you open it, the negative electricity will pull all the particles in the air. And again, we wash the pocket, we change our gloves, we clean the skin and we put the implant. First, 90 degrees and we turn it in the pocket and the indicator at the bottom of the implant should stay at six o'clock. Then while suturing, the fascia should be sutured both to that scarpa layer and to deep fascia. But while putting the sutures, the breast should be pressed down to imitate if the patient is standing up. If you do not do this, you will have an irregular inframammary fold and high-seating implants. If the patient's arms are closed, it is not important. But it's especially important in polyurethane coated implants. And then we make the suturing, skin suturing. This is an example, again another one, dual planar implantations. And after pregnancies also, dual planar is a better choice because this is after two pregnancies and 10 years and you see implants are still staying high and in this patient also. Animations problems are important because animations problems seen in this type of implantations, dual planar implantations, this is acceptable. However, especially in periodontal approaches, they may be very severe and these can only be corrected by implant replacement to the subfacial plane. Especially augmentation mastopexy, scarring between skin and muscle is more dense, so animations problems are usually worse and in this patient also implant change to subfacial layer. Another problem with dual planar is glanular apoptosis may result in waterfall deformity. If it happens, you need to make a mastopexy procedure. The advantages of subfacial plane is it's a more natural implant plane, better integration with glanular tissue, especially in myopitosis, less painful and shorter healing period. However, it needs sufficient tissue thickness in upper pole. Lower pole should be firm enough to support the implant. Otherwise, breast pitosis is exaggerated in time. Smaller and lighter implants should be preferred and if necessary, fat correcting for the implant edges. This is subfacial planar augmentation. It is a more difficult dissection because you need to make sharp dissection and it's a bleeding area. It takes more time. It should not be used in patients' subfacial augmentation with loose lower pole that cannot support the implant because pitosis in long term will occur and smaller and lighter implants should be preferred. You can see the pitosis in long term in this patient or even in augmentation mastopexy procedures, subfacial plane can exaggerate the pitosis. In subfacial augmentations, even the patient has tight skin in long term, she may have small pitosis and after weight loss, the implant can be more visible. To reduce the implant visibility, fat injections are very useful. It is called shortened mammoplasty. In subfacial augmentation, the medial and upper border can be camouflaged by fat injections. It also improves skin clarity. From the diet resistance areas to a sterile canister with sharp hold cannulas. In skinny patients with wide intermammary distance, it is not possible to get a narrow cleavage. Fat injections will be helpful. Trying to place implants too medially over the sternum will cause medial border irregularities, synmastia, implant visibility and wrinkling. In patients with laterally located nipples, trying to narrow the cleavage by placing implants medially will increase the divergence angle of the nipple axis. Nipples should be located at the midpoint of the implant base. In patients with wide intermammary distance, fat injections will be effective in narrowing the cleavage such as in this patient six years later. Patients with two laterally located nipples usually have also a sloped chest wall with prominent sternum, pectus carinatum. Implants widen the cleavage. Trying to put implants too medially will cause outward rotation of the nipple axis. Increasing the volume of medial chadron with fat injections and creating cleavage is a better solution for these patients. As the muscle contraction will move the implants laterally, superficial augmentations should be preferred in that type of patients. This is an example with pectus carinatus and the cleavage is filled with fat injections and superficial augmentations. Dr. Yücel, could you please wrap up? One minute, I am finishing. Patients with two medially located nipples usually have also flat thorax and depressed sternum, pectus excavatus. Implants always tend to migrate medially in these patients. Larger implants with wide base will cause both synmastia and inward rotation of axis of nipples. Dual plate should be preferred to avoid synmastia and high profile implants will exaggerate the depression of the sternum. So, fat injections to the medial border and over the sternum will be useful to improve the deformity and correct the synmastia. This is a reconstruction patient and correction of synmastia. Again, correction of synmastia, implant change. Again, another one. In breast augmentation, implant is placed according to existing nipple position. If nipples are not symmetrical at the horizontal plane, either implants will be located asymmetrically or the nipples will not be centralized. Fat injections is a good solution for asymmetrical cleavage such as in this patient. In the second operation, fat injection and larger implants are used. The last word, the anatomy and tissue quality says the last word. Best patients are patients with good tissue quality, thick cutaneous tissues and in all techniques, the least satisfactory results in that type of patients. Decision making before surgery is the most important step in breast augmentation, but our surgical strategies will be changed in the near future because of the ALCL issue. Okay, thank you very much for your attention. Sorry for I missed my time. Thank you very much, Dr. Yücel. I think it was a very impressive lecture and we will take the questions after the second speech which will be made by Professor Selahattin Özmen. And I would like to invite him. He's going to talk about the complication management, prevention and management in breast augmentation. Dr. Özmen, please. Thank you, Dr. Erhan. I will start my time. First, good evening and good afternoon, everybody. And I want to thank ASPS for inviting us for this presentation. It's a long topic, but I will try to wrap up it very quickly. I have no disclosure. We've been told that breast implantation is very easy. Just put 250 or 300 mm implant and it's done. But now we see that there are a lot of different body types and a lot of implant choices. That's why, as Dr. Yücel told, it's very important to do very good planning before the surgery. By this, we will have good results. But without good planning, we may have a lot of complications related to breast augmentation. Hematoma, infection, capsular contracture, sensory change, rhythmic malposition are common complications. ALCL is a big question for us for the next future. When we look at the reoperation rates, it's up to 20% for primary cases and even higher for secondary cases, up to 34% of cases. When we look at the literature, there are a lot of studies, but the problem here is the lack of studies with a high level of evidence. And most of the reviews are depending on the studies before 2000. And there's a new issue, biofilm, and it may be a reason for ALCL, capsules, and many things. But we know that since 2000, the important complication rates seem to be very low when we check the literature. When we look at the complications, we can classify the etiology of the complications into three patient-related complications, implant-related complications, and surgical technique-related complications. Patient-related parameters are usually unavoidable. We should adapt them. The anatomy shape of the breast, chest wall, tissue thickness, and general health condition of the patient, high blood pressure, bleeding tendencies, weight changes, pregnancies with pectus carinatum, with very short IMF nipple distance, asymmetries, large nipple or complex asymmetric breast shapes with tuberous breast. And these are all problems. And severely athletic patients, women, are also problems. Here we can see a Follan syndrome patient, quite difficult. Complications, bleeding and hematoma is an important complication. It's rather high. In this particular patient, there was a bleeding tendency. She's a doctor, but she didn't mention this before. After one week, she had this hematoma. To prevent hematoma, light restrictors and careful hemostasis are very important. Drainage should be used for me. Elastic bandages, I use them in all patients. Cold application is a routine for me. And sometimes with bleeding tendencies, we can use transamin. This is a very rare case for me, but it's important. Psychological issue may be here. You can see. The patient was augmented with 390 extra high implants. She was happy with the result, but due to her religious belief, she wanted the implant out. After three months, I took it out. When we look at the implant's related parameters, filler materials, maybe saline, silicone, envelope change, shape of the implant, diameters of the implant, projection and volume are very different. In USA, predominantly saline implants are preferred, but in the rest of the world, silicone implants are preferred due to their better feel and durability. When we look at the saline implants, using smaller incisions and cheaper price is an advantage. There are some studies, they say that less capsular contact with the saline implants, but rippling, palpable irregularities, unnatural feeling, leakage and deflation rates may be a problem with the saline implants. There are some new implants. Recently, idle implant was introduced in USA, but I have no experience with this to overcome the drawbacks of the saline implants. Silicone implants are very common. There are many different brands with different shapes, different projections. And even there are some lighter implants recently introduced to the market with air bubbles up to 28% lighter than compared to the normal silicone implants. There are different brands, as you know. Usually, in silicone implants, we have 1, 2 or 3 gels inside and this is an advantage, but we should be careful because all these implants should be filled with medical grade silicone. Rippling is a complication, especially with less cohesivity and with saline implants. With slim patients, it's more complicated. That's why higher cohesivity shaped implants is good to overcome rippling. Submuscular placement and fat injections may help as well. Rupture and deflation may be a problem with both saline and silicone implants, but with saline implants, deflation is very visible by the patient. Two previous deflations, saline implant on the left side, you can see, and a third deflation, she came to me, I put a silicone implant to reconstruct the area. In this particular patient, you can see here, right breast intra-capsular silicone implant rupture. It's not very visible, but this capsule, I did capsulectomy, the implant changed. Another particular patient, you can see that this intra-capsular rupture and I examined her with MRI, but they didn't mention any specific finding other than intra-capsular rupture. During the operation, I saw that there are some nodules in the capsule and I wasn't comfortable. I didn't put implants and waited for one month. After I had all the pathologic results, histologic results, I reconstructed her with a mentor cohesive implant. Shell surface differs very much. There may be smooth surface, textured surface, or polyurethane surface. The surface manufacturing techniques are different. Soft-gloss, vulcanization, imprinting, or nanotechnology are in the market. Capsular cone structure is independent of the type of the implant field. It's almost like this. There are some other studies, but it's believed that it's independent. But texture or smooth surface effect is. Bansley reported that there's a protective effect of texturization on capsular cone structure, but it's not significant in submuscular placement. Wong et al. also reported that texturization has an effect on capsular cone structure reduction, especially in subground. The gold standard for the capsular cone structure, nowadays thinking about ALCL, is capsulectomy together with site change and implant exchange. But creating a no-pocket from subglundal to subpectral or through dual plane is a choice. Shaped implants should be chosen if it's already subpectral pocket. Irrigation is important. Polyurethane cohesive implants can be used for recurrent capsules. There are some other solutions like alloderm or some locotrion antagonists, but they are not commonly used. Some of the capsule cone structures are not very severe, but some of them are really problem and they are with ptosis and some other problems. That's why you should do mastopexy together with a capsulectomy. As in this case. Another parameter is anatomic or round implants. Bronze reported that it's almost impossible to distinguish between round and anatomic implants. Also, Friedman reported that in the hands of an experienced surgeon the aesthetic result is similar. There's no difference. Kaplan reported that capsular cone structure and rupture is less with anatomical implants with high cohesive implants. Weike reported that malrotation is high especially with anatomic implants. Also, Schutz reported high malrotation rate with style 5-10 anatomic implants. Liszt et al. reported 5.2% malrotation with Allergan style 4-10 implants. With mastopexy with bigger pockets we have more risk for malrotations and with capsular the malrotation is more severe. This is a patient that has animation deformity as you see. Also, she states that every morning when she wakes up her implant is rotated. To prevent this creating a normal pocket without big extensive margins and just obeying the rules on the rulers, on the markers, on the implants using tight bra is important for this and avoiding vigorous massage after operation is important for at least one month. Surgical technique is another important topic. Planning before surgery, using antibiotics, incision size, length and implant pocket selection pocket irrigation solutions, etc. are very important. When we look at the operation rates if you are going to use such a gel inside the breast for the augmentation it's very common actually in Turkey some of the non-plastic surgeons even are placing this and it's a really big problem and if you have such a patient and you clean the breast I don't prefer to use at the same session the implant. You should wait at least 2 or 3 months because it's not easy to clean all the gel from the breast. Also a bad plan can cause undesired shape of the breast as you can see here and it's not easy to correct the deformity in all of the patients. When we look at the antibiotic use Arako et al. reports that pocket irrigation with antibiotics is protective against infection but drains significantly increase the risk of infection. Kahn reported that a single preoperative intravenous antibiotic is the best to prevent the infection. On the other hand, Mirza Beygir reported that there is no reduction in infection capsule construction or total complication rate by using antibiotics or not. Also, Hartwicker reported that there is no effect on infection rates using antibiotics or not. We can see that without any prophylaxis the infection is lower in their study. Therefore, there is no documented evidence on using antibiotics if they decrease the infection or not but still we see that using a triple antibiotic or some other washing solution or antiseptic solution inside the breast may reduce the capsular bone structure. Thinking about the biofins and the role of antibiotics in the prevention of biofins therefore capsular bone structure and ALCL I think we should use at least a preoperative antibiotic for the prophylaxis. I myself prefer to use five-phase antibiotics. When we look at the surgical approach incisions are important mostly inframammary and parietal incisions are preferred but there are some other choices as well. When we look at the incisions, they are usually four to six centimeters, but with highly cohesive implants, we need to use up to one centimeter longer incision. Too short incision may create trauma to skin edges or implants, and insertion devices doesn't decrease the incision length. Romani et al. reported that endoscopic transaxillary and inframammary incision can be used without any difference, but patient satisfaction is higher in transaxillary incision. Stuttman reported that postoperative complications are not associated with incision, but on the other hand, Vienner reported that there is significantly higher complication capsular contracture with perioral incision. Also, Jacobson et al. reported that the highest capsular contracture is with transaxillary incision, and the least complication is with inframammary fold incision. When we look at the sensitivity, O'Quird et al. reported that with perioral incision, there is less sensory loss in the lower fold area. On the other hand, Moffitt et al. reported that between areolar incision and inframammary incision, there is no difference in sensory outcomes. But Arako et al. reported that with perioral incision, there is three-fold risk increase with sensitivity loss and areolar hypersensitivity when compared with IMF incision. Using barbed sutures like V-LAC or Stratafix, we can shorten the incision up to 3.5 cm from 5 cm, and this is also good to prevent scars. But sometimes scar movement is a problem. It can move upwards or downwards. That's why suturing the fascia in the incision area to the bottom with two or three bifil or monocular sutures will help and prevent the movement of the implant and the scar. Metriculous layer suture is important. Taking for at least one month, I even tell patients to use the strips for three months or two months, refreshing the skin edges when needed, and placing the scar exactly to new IMF will lower the scar problem. This type of omni-strips are very useful for prevention of the scar winding. Also, in this type of periorolar mastectomy, scar winding very much, and to prevent this, a very small circle should be chosen, and usually I use thorogortex suture for this type of scar revisions or periorolar mastectomy. Pucket dissection is important as well. Ultramarine sharp dissection should be chosen. I use Megadine pinpoint cortis as you can see here. Blunt dissection is more painful as there's prolonged recovery. Without careful dissection, you may have this type of problems. They did an operation three months ago, and she had a lot of wounds on the breast, but we could save the breast and implant. Skin mastectomy is another problem. In this type of mild cases, we can use this type of garment, but a problem like this should be corrected. Three previous operations, as you can see here, a big bulge as well, and there's a deformity. She had pain, and a new pocket was created with scar revisions. There were two different implant types, and the outcome was this. Scar revision will be planned for the next operation. I think my time is over, but I need two more minutes. Implant location can be subglondular, submuscular, subfacial, or lower plane. Extrusion has effect on the subglondular location, but it has no protective effect in submuscular location. Also, Shaub et al. reported the same thing. Submuscular location has a lower capsular cone structure, but it's loosely supported. With submuscular location, you have better upper pole cover, but more animation deformities and more implant displacement. Also, with submuscular implants, you have a little bit higher amount of distortion and rotation, mal-rotation, but rates of satisfaction is similar with all the planes. There's no difference in complication rate for patient satisfaction in a retrospective study reported by Brown et al. And Tebets introduced dual plane. Dr. Hüccel talked about this. I'm not going to talk too much. Animation deformity is an important parameter, especially in submuscular placement and like this pararollar incision. Also, waterfall deformity is important. I think I see it a lot, especially if you have ptosis and you don't do mastopexy and use submuscular or subfacial planes, it has a gliding effect and tissue sags over the implant. Implant stays higher. You have waterfall deformity like this. In this particular patient, mastopexy together with implant change and capsular cone was applied. Double capsular late thrombus is a problem, especially after one year. It's a late thrombus. And thrombus is a big problem when we think about ALCL. It's evidence of ALCL in some of the patients. In this particular patient, we did ultrasound associated sampling and we avoid the ALCL risk. Then we change the implant and did capsular ectomy. It's almost over, Suhan. Double capsular is another problem. She has ptosis with double capsular. And you can see here, we have two capsules on the area. Mastopexy together with capsular ectomy was done. ALCL is a big problem. It will change everything, I think. The most common presentation is late thrombus. Mast tumor erosion, lymph node metastasis may be the evidence. Especially micro-textured implants are related to, especially biocell textured implants, are related to this ALCL. But all brands can cause ALCL. It's known like this. Using nipple shields prevents bacterial contamination. Repeated antiseptic. No-touch technique using insertion tunnels. Using light refractor and careful hemostasis will help. Packet irrigation is important. Non-powder glow use and glow changing is important during operation. And I think you all know about this 14-point plan. I don't agree with using drains. I think drains are important because if you leave some blood in the area, it's a good source for bacterial inflammation. Thank you for your attention and I think we can have the questions. Okay. Thank you very much, Selahattin. I think it was a great lecture too. And as I would like to invite all the participants to ask their questions via the chat screen. And in the meantime, I would like to tell the participants that these two gentlemen are very experienced and very good surgeons, especially in breast surgery. And before getting to questions, I would like to raise some discussion and I would like to ask their personal experience in the following question. So we are living in the ALCL era. So although Dr. Oseman has pointed out a little bit, how did this make a change in your daily practice and how did you make any change in your implant selection strategy or did you make a change in your surgical technique, your site of incision or surgical plane? I would like to ask both of you. Maybe I can start with Dr. Yücel. Thank you, Suhan. And thank you, Selahattin. It was a very nice lecture, very enlightening. After ALCL, you know, I have a case also, an ALCL case, the first case in Turkey. But I completely changed the implant. I was using macro-textured implants. Now I changed it to micro-textured or nano-textured implants. But I still prefer anatomical implants in many of the patients. I still use inflammatory fold incisions, and this is also recommended. I use sometimes round, smooth implants, but if the patient is suitable and if the patient wants it, if the patient insists on a round smooth implant, I use it. But I don't like it a lot because it causes more capsular contracture, I think, from my old experiences. I have not used round implants for many years, smooth implants, but before when I was using them, contracture rates were higher. But if patients want, yes, I use. Okay. Dr. Özmen, do you have an answer for that? I think I cannot start my video. Yes. I am obeying almost all the rules on the 14-point implant, and I think I was using this thing before this ARCL issue as well. But I'm very careful about antiseptic and repeated antiseptics of the incision site and using some cleaning solution, antiseptic solution, for inside of the pocket and for the implant as well. And I don't open the implant before placing it. I take my time and make the time very short to open the pocket and put it into the breast pocket. I'm using drains. I believe that the blood inside the pocket is not a good thing, and it's a good source for the inflammation and bacterial overgrowth. Other than this, I'm still using textured implants. I think we have very high rates of contracture, especially smooth implants, and we should judge between the smooth implants, capsule contracture, and less capsule contracture with textured implants, because every operation is another risk for the patient, and ARCL is not a very common disease. And if we are careful, I think we will not have too many cases in the next future. Yeah. What about seeing late seromas? Are you seeing more and more late seromas, do you think, Selahattin? I think we are more careful about this. I don't think we are seeing more and more, but patients are afraid, and we are examining them with MRI more frequently. That's why we can see late seroma, even if it's not very distorting the breast, even if it's not very exaggerated, we can detect it. And if we detect it, we do some tests from the police. But I don't think it's a very high rate compared to previous patients. Dr. Yücel, do you agree with Dr. Özmen about seeing more and more late seromas, or there is no change in seroma rates? In microtextured implants, yes. I have used microtextured implants for a couple of years, and after four or five years later, I have seen not too much, but I have seen patients with, I cannot give a percentage, but there are more late seromas, yes. I always take seroma out and send to histological examination, because it should be done before the revision surgery. You need to make the diagnosis if there's ARCL or not. I would like to tell my experience. I think I agree with you. I'm seeing more and more late seromas, actually, and it's not depending only the texture. There are different types of implants, and I think I'm seeing more and more late seromas. What about breast implant illness? In the United States, breast implant illness is a very widely used terminology. Do you observe any kind of breast implant illnesses in your patients? And how do you follow your patients? Do you follow them long enough, and do you ask them if they have dry eyes or rheumatoid arthritis and whatever? Do you ask about that? Actually, no, I don't ask, but I didn't hear any problems like this from any of the patients. I do a lot of implants, but I have not had this type of problems. In one patient, I had red breast syndrome. It was a reconstruction, actually, but it healed by itself, but I have not seen that sickness. I mean, if my patients have it, I don't know either. Okay. Dr. Osman, do you have any experience with that? I have two patients contact me through internet. One of them was from Germany, one of them was from USA, but I didn't operate them about breast illness. But in Turkey, none of my patients asked me such a thing because I follow them for many years. They can contact me every time. My phone, mobile phone, all time is on. They can reach me, and I've never heard a patient with breast illness in Turkey so far. Okay. Thank you very much. And there is one question from the participants. Ms. Doğa Kuruğlu is asking about your experience with subfacial implants with regards to the rate of capsule contracture comparing to the subglandular implants. So, can you compare subglandular and subfacial implants in terms of capsule contracture in your experience? Do you want me to answer? Yeah, please. Uh, you know, we are from the same institution, and in Gallaudet University, we use subfacial technique in many patients. And in my experience, I have never had a patient with severe capsule contracture in subfacial planning. And I think it's not only one factor, it's multifactorial, but the subfacial plan is a good plan to me. Only, I don't recommend it in total patients without mastopexy because if you put the implant to me, you have multiple deformity in higher rate with the subfacial plane. But other than this, you can use subfacial, you can use dual plane. Uh, these are my preferences and you can use submuscular plane, I think. Subglandular plane to me is only effective in total patients without mastopexy. You can use polyurethane implants and you can texture the implant with this type of packet selection. But otherwise, subfacial is a good choice for me. Okay. Dr. Yücel, I know that you use more and more dual plane, but do you have any experience with subglandular and subfacial? Yes, I have used subfacial plane for maybe for two, three years, almost every patient when I was making composite mammoplasty. I think the difference, I cannot say a percentage, but I don't see a lot of capillary contractures. Even if I see, I don't see a lot of permanent relapsing capillary contractures. But I have seen a recurrent capillary contracture in patients if they come from another surgeon to me with a severe capillary contracture. When I try to correct it, sometimes it recurs. I think in that type of patients, it is a problem in patient's tissue. It doesn't only because of the surgeon. But the difference between the rate of capillary contracture is not because of the implant site, I think. I think less cohesive implants are more, we see the capillary contracture in low-cohesive implants because it loses its shape. But the anatomical implants are form-stable and they are more resistant to contracture. Also, the plane is important. That means if it is under the muscle, it is under the muscle, the muscle covers over it and it can be, capillary contracture heightens better. I don't think that there is a great difference because of the plane, but the difference is because it gives better camouflage to our plane and the most important thing is the cohesivity of the gel, I think. Okay, great. Thank you very much. I believe there are no more questions in the chat screen. That brings us to the end of the webinar, actually. I would like to thank Professor Akin Yücel and Professor Selahattin Özmen for their very valuable experience and sharing their experience with us. As I told you in the beginning, it's a great privilege for us to participate in this webinar series with the ASPS and being a global partner with the ASPS, I think it's quite an opportunity for us to meet new people and to address new people and make connections. So, I would like to pass our gratitude to the American Society of Plastic Surgeons. I believe we are, it's one hour and six minutes. I think it's very acceptable for us to finish the session only six minutes ahead. Thank you and thank you for inviting us for your webinar. Thank you. Thank you to everyone. Thank you so much for the moderation and thank you for the invitation. And I want to thank Laura Weber, Romina Valadez, Cassandra Lutz and other team members and so on to you for moderating. And goodbye everybody. Good evening. Good afternoon. Bye-bye. Thank you. Bye-bye.

breast augmentation

implant selection

surgical techniques

complication management

BIA-ALCL

patient anatomy

plastic surgery

risk minimization

safety protocols

anatomical implants

Professor Suhan Ayhan

Professor Akın Yücel

Professor Selahattin Özmen

breast implants

round implants

ALCL

patient safety